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Insurance Policy - Sunlife Assurance Medical/ Drug Benefit (2005 - 2007)
Sun Life Assurance Company of Canada STOP-LOSS POLICY Policyh i lder: City of Renton Policy umber: 69026 Policy ffective Date: January 1,2005 This Pol cy is delivered in Washington and is subject to the laws of that jurisdiction. Sun Lif:Assurance Company of Canada agrees to pay the benefits provided by this Policy in accordance w th the provisio i s contained herein.This Policy is issued in consideration of the Application submitted by the Policyh s lder, a copy of which is attached,and continued payment of premium by the Policyholder.The Applica lion, Special Risk Questionnaire,and any Riders,Endorsements'and Amendments to this Policy are made part,of t i is Policy. The Policyholder will hereafter be referred to as"You,""Your,"and"Yours." Sun Life Assurance Company of Canada will hereafter be referred to as"We,""Our"and"Us." When d.'termining any date under this Policy, all days begin at 12:00:00 a.m. and end at 11:59:59 p.m. stand and time for Your headquarters. Signed .t Our U.S.headquarters,One Sun Life Executive Park,Wellesley Hills,Massachusetts,by: /1 President Secretary PLEASE READ YOUR POLICY CAREFULLY Non-Participating This is . reimbursement policy.You,or Your Plan administrator,are responsible for making benefit determ nations under Your Plan.We have no duty or authority to administer,settle,adjust or provi e advice egarding claims filed under Your Plan. Sun* * Sun Life ssurance Company of Canada is a member of the Sun Life Financial group of companies.©2002 Sun Life Assurance Company of Canada,Wellesley Hills,MA 02481.All rights reserved. Life Financial' 02-SL Table of Contents Section Description Page Schedule of Benefits iii I Definitions 1 II Benefit Provisions 4 • Specific Benefit 4 • Aggregate Benefit 5 • Eligible Expenses 6 • Limitations and Exclusions 8 III Claim Provisions 10 IV Your Rights and Responsibilities 12 V Our Rights and Responsibilities 15 VI General Provisions 17 • Premium Provisions 18 • Termination Provisions 18 02-SL ii Schedule of Benefits Specific Benefit I , Original Specific Benefit Effective Date January 1,2005 Benefit S•ecifications Policy ear January 1,2005 through December 31,2005 Reimb sement Percentage 100%of Eligible Expenses Covere' Benefits Medical Prescription Drug Plan(PDP) Specifi Benefit Deductible $140,000 Specifi Benefit Lifetime Maxim Reimbursement $860,000 Specifi Benefit Claims Basis 24/12(12 Month Run-In) Eligible Expenses include only those expenses Incurred during the Policy Year,or within 12.months prior to the Policy ear (the"Run-In Period"),and Paid during the Policy Year. Covered Unit(s) Single Employee,Employee and Family Retirees Not Covered Specific Benefit Premium Rate $12.63 per Single Employee per month $32.56 per Employee and Family per month Premium Due Date The Policy Effective Date and the first day of each succe ding month. V fr 02-SL iii I i Schedule of Benefits Aggregate Benefit Origina Aggregate Benefit Effective Date January 1,2005 Benefit S I ecifications Policy ear January 1,2005 through December 31,2005 Reimb sement Percentage 100%of Eligible Expenses Covered Benefits Medical Prescription Drug Plan(PDP) Aggre Late Benefit Maximum $1,000,000 Aggregate Benefit Maximum Eligible Expenses Per Covered Person $140,000 Aggre_ate Deductible Factor("ADF") The ADF per Benefit Month for each Covered Unit by Covered Benefit is as follows: Covered Benefit Covered Unit ADF Medical Single Employee, $1,10 .95 • Employee and Family PDP Single Employee, $348. 5 Employee and Family Minim m Aggregate Deductible The Minimum Aggregate Deductible for the current Poli y Year is the greater of: a) $11,087,507; or b) 90%of the Monthly Aggregate Deductible for the fir t month of the Policy Year,then multiplied by 12. Aggregate Benefit Attachment Point The Aggregate Benefit Attachment Point is the greater o a) the sum of the Monthly Aggregate Deductibles for th Policy Year;or b) the Minimum Aggregate Deductible. Aggregate Benefit Claims Basis Paid Eligible Expenses include only those expenses Paid during the Policy Year. Cover:d Unit(s) Single Employee,Employee and Family Retire;s Not Covered Aggregate Benefit Premium Rate $1.00 per Policy Year. Premi m Due Date The Policy Effective Date and the first day of each succe-ding Policy Year. 02 SL iv • Section I Definitions Alitern.tive Care: For the purpose of determining Eligible Expenses under this Policy,Alternative Care means a plan of Treatment,identified through case management services provided to Your Plan,which may not be covere• under Your Plan,but which We may consider for reimbursement because the Treatment is cost-ef ective and M:dically Appropriate and Necessary for the care of a Covered Person.Alternative Care must satisfy the require ents set forth in Section II,Expenses Eligible for Reimbursement. Benefi Month: Any calendar month during which this Policy is in force. 1 Catast ophic Diagnosis:Any medical condition which is a special risk on Our Special Risk Questionnair . Claim• Basis: The period of time, shown on the Schedule(s)of Benefits, during which Eligible Expenses must be Incurred by a Covered Person and Paid by You to be eligible for reimbursement under this Policy. Cover d Benefits: The benefit provisions of Your Plan that are insured for stop-loss coverage under this olicy. The C vered Benefits for this Policy are shown on the Schedule(s)of Benefits. Cover d Person: A person enrolled in Your Plan and entitled to receive benefits under Your Plan while this Policy's in force.Retirees,as defined by Your Plan,may be Covered Persons if they are included on the Sched e(s)of Benefits. Cover d Unit:A category of participants under Your Plan.The Covered Unit(s)for this Policy are shown on the Sched le(s)of Benefits. Depen ent:A person enrolled in Your Plan and entitled to receive benefits under Your Plan as a depende t of a Cover d Person. Drug r Alcohol Dependence:Dependence on,or abuse of,a chemical substance or alcohol as classified y the curren edition of the Diagnostic and Statistical Manual of the American Psychiatric Association("DSM")or a compa able manual if the American Psychiatric Association stops publishing the DSM. Exper mental or Investigational Treatment:For the purpose of determining Eligible Expenses under th s Policy a Treatment(other than covered Off-Label Drug Use)will be considered by Us to be experimental or investigational if: 1. The Treatment is governed by the United States Food and Drug Administration("FDA")and the DA ' has not approved the Treatment for the particular condition at the time the Treatment is provided;or 2. The Treatment is the subject of ongoing Phase I,II,or III clinical trials as defined by the National Institute of Health,National Cancer Institute or the FDA; or ' 3. There is documentation in published U.S.peer-reviewed medical literature that states that further research, studies,or clinical trials are necessary to determine the safety,toxicity or efficacy of the Treatment. Incur ed: The date on which Treatment is provided. Indep•ndent Review Panel: A panel retained through a third party vendor of medical review services th t is compr sed of three physicians who are board-certified in the medical specialty or subspecialty that most typically admin sters the Treatment under review. Medi bal Management Vendor: A third party hired to reduce or control the cost of services or supplies p iovided to Co ered Persons under Your Plan. 02-SL 1 Section I Definitions Medic.By Necessary and Appropriate: For the purpose of determining Eligible Expenses under this Poicy,a medic.I ly necessary and appropriate Treatment is one that We determine meets all of the following criteri : 1. It is recommended and provided by a licensed physician,dentist or other medical practitioner who is practicing within the scope of his or her license;and 2. It is generally accepted as the standard of medical practice and care for the diagnosis and treatmen of the particular condition; and 3. It is approved by the FDA, if applicable. Menta Illness:For the purpose of determining Eligible Expenses under this Policy,Mental Illness include s,but is not 1 mited to,bipolar affective disorder,schizophrenia,psychotic illness,manic depressive illness,depression and depressive disorders,anxiety and anxiety disorders and any other mental and nervous condition classified in the DS .Mental Illness does not include any condition listed in Appendix G of the DSM-IV,titled"ICD �9-CM Codes or Selected General Medical Conditions and Medication Induced Disorders,"or any comparable li ting if Appen p ix G is no longer published. Off-L.bel Drug Use: The use of a drug for a purpose other than that for which it was approved by the FDA. Origi al Aggregate Benefit Effective Date:When We provide You with Aggregate Benefit coverage under this Policy for consecutive Policy Years,the Original Aggregate Benefit Effective Date is the date Aggregate enefit coverage first became effective in the consecutive year period. Origi al Specific Benefit Effective Date: When We provide You with Specific Benefit coverage under t is Policy for consecutive Policy Years,the Original Specific Benefit Effective Date is the date Specific Benefit coverage first became effective in the consecutive year period. Paid: I he date Your check or draft for payment of expenses Incurred by a Covered Person is issued and delivered to the p ayee,provided that the account upon which the payment is drawn contains sufficient funds to permit the check or draft to be honored. Plan: our self-funded employee benefit plan established to provide benefits to Covered Persons as desc 'bed in Your plan document.For the purpose of determining benefits payable under this Policy,the Plan shall not include any a 0 endments made to the plan document after the Original Aggregate Benefit Effective Date or the 0 'ginal Speci c Benefit Effective Date,whichever is earlier,unless We notify You in writing from Our U.S. Headq afters that We accept the amendment. Policy older: You,the legal entity to whom this Policy is issued. Presc iiption Drugs:For the purpose of determining Eligible Expenses under this Policy,Prescription D gs includ•s all prescription drugs covered under Your Plan, other than prescription drugs administered to a overed Perso while he or she is confined in a hospital or other medical facility. - Presc iption Drug Plan:A benefit provision of Your Plan, or a separate employee benefit plan maintain d by You, der which prescription drug expenses are paid independently of other medical expenses.Expense incurr d under a Prescription Drug Plan will be included as Eligible Expenses only if the Prescription Drug Plan is incl ded as a Covered Benefit in the Schedule of Benefits.A Prescription Drug Plan does not mean prescription drug e•penses paid subject to any deductibles and coinsurance applicable to other medical benefits under Your Plan. • Provi 4 er Network:A Preferred Provider Organization(PPO),Exclusive Provider Organization(EPO),Point of Service Plan(POS),self-funded Health Maintenance Organization(HMO), or any managed care network offered under our Plan. Reim ursement Percentage:The percent of Eligible Expenses that will be considered for reimbursement under this P licy. 02-SL 2 Section I Definitions Sched.le of Benefits:This Policy's schedule of Specific Benefit coverage or Aggregate Benefit coverage provid d under this Policy. Specia Risk Questionnaire: A report used to provide Us with certain information We require to underwrite this Policy. Third 'arty Administrator("TPA"): A third party that You have entered into an agreement with to provide admin. trative services to Your Plan.Your TPA is not Our agent. Trans►lant: The transplant of organs from human to human.For the purposes of determining Eligible Ex enses under this Policy,Transplant includes only the following transplants: heart,heart and lung,lung(single or double),liver,kidney,pancreas,kidney and pancreas,human bone marrow and stem cell transplantation a d reinfu ion.A Transplant must be performed at a Transplant Facility in order to be considered for reimburs ment under this Policy. Skin and Cornea transplants are not considered a"Transplant"for the purpose of determining Eligibl- Expenses under this Policy,but are considered Eligible Expenses if covered by your Plan. Trans s lant Facility:A hospital or facility which is accredited by the Joint Commission on Accreditation of Health are Organizations to perform a Transplant and: Fo organ transplants: is an approved member of the United Network for Organ Sharing for such Transplant or's approved by Medicare as a transplant facility for such Transplant. I Fo unrelated allogeneic bone marrow or stem cell transplants: is a participant in the National Marrow Donor Program. Fo autologous stem cell transplants: is approved to perform such Transplant by: (a)the state where tlr Tr;nsplant is to be performed; or(b)Medicare; or(c)the Foundation for the Accreditation of Hemop ietic C:11 Therapy. Outpatient facilities must be similarly approved. Treat ent:Any treatment,procedure,service,device,supply or drug provided to a Covered Person. Usual and Customary Fee:For the purpose of determining Eligible Expenses under this Policy,"Usual" eans the fe:usually charged for a particular service by a provider;"Customary"means a fee in the range of us al fees charged by similar providers in the same geographic area. U.S.Headquarters: Our United States headquarters located at One Sun Life Executive Park,Wellesley Hills, Massachusetts. I 02-SL 3 I I • Section II Benefit Provisions Specific Benefit Defini 'ons Sp cific Benefit Deductible: The amount of Eligible Expenses relating to a Covered Person that You must pa before You become eligible for a Specific Benefit.The Specific Benefit Deductible is shown on thie Sc edule of Benefits.In no event will the Specific Benefit Deductible be less than 5%of expected clai or $1 0,000,whichever is less. Sp cific Benefit Lifetime Maximum Reimbursement: The maximum amount We will ever reimbur e with res•ect to any Covered Person. The Specific Benefit Lifetime Maximum Reimbursement is shown on e Sc•edule of Benefits. Speci c Benefit The S•ecific Benefit for any Covered Person for any Policy Year equals: 1. the total amount of Eligible Expenses for the Covered person;minus 2. the Specific Deductible; m ltiplied by the Reimbursement Percentage shown on the"Schedule of Benefits-Specific Benefit," f that Re mbursement Percentage is less than 100%. The S•ecific Benefit payable with respect to any Covered Person is subject to the Specific Benefit Lifetim Maxi• urn Reimbursement. 02-SL 4 ' I Section II Benefit Provisions Aggregate Benefit i Defini ons Ag regate Benefit Attachment Point: The amount of Eligible Expenses You must pay during the Aggregate Be efit Claims Basis before We will consider an Aggregate Benefit claim.The Aggregate Benefit Att4chment Po' t is shown on the Schedule of Benefits.In no event will the Aggregate Benefit Attachment Point be less tha 120%of expected claims. Ag regate Deductible Factor: The deductible factor per Benefit Month per Covered Unit by Covered Be efit.The Aggregate Deductible Factor for each Covered Benefit is shown on the Schedule of Bene its. Ag regate Benefit Maximum Eligible Expenses per Covered Person: The maximum amount of El' ible Ex enses for any one Covered Person that will be used to calculate the Aggregate Benefit.The Aggregate Be efit Maximum Eligible Expenses per Covered Person is shown on the Schedule of Benefits. M' imum Aggregate Deductible: The minimum amount of Eligible Expenses You must pay before ou be 1 ome eligible for an Aggregate Benefit.The Minimum Aggregate Deductible is shown on the Sche ule of Be efits. M o nthly Aggregate Deductible: The sum of the deductibles for all Covered Benefits for each Benefit ' Month. The deductible for each Covered Benefit is calculated by multiplying the number of Covered Units on the first day of the Benefit Month by the Aggregate Deductible Factor for each Covered Benefit.The ca ulation of the Monthly Aggregate Deductible is subject to the 5%Adjustment Rule. 5° Adjustment Rule: If the Monthly Aggregate Deductible decreases from one month("Month A")to the ne t("Month B"),for any reason,the Monthly Aggregate Deductible for Month B shall not be less th n 95% of he Monthly Aggregate Deductible for Month A. Aggre;ate Benefit The Aggregate Benefit equals: 1. the total amount of Eligible Expenses for all Covered Persons,subject to the Aggregate Benefit Maximum Eligible Expenses Per Covered Person;minus the greater of 2. the Aggregate Benefit Attachment Point or the Minimum Aggregate Deductible; m ltiplied by the Reimbursement Percentage shown on the"Schedule of Benefits—Aggregate Benefit,"if th.t Reimbursement Percentage is less than 100%. The A.geegate Benefit will be calculated after the end of the Aggregate Benefit Claims Basis. Aggre,ate Benefit Maximum ' The A:gregate Benefit We will pay will not exceed the Aggregate Benefit Maximum shown on the Schedule of Benef s. 1 02-SL 5 Section II Benefit Provisions Expenses Eligible for Reimbursement Eligibl• Expenses Eligibl Expenses include any amount paid by You for Medically Necessary and Appropriate expenses incurred by a Covered Person which: 1. Have been paid in accordance with the terms of Your Plan;and 2. Were Incurred and Paid during the applicable claims basis;and 3. Are paid under a Covered Benefit shown on the Schedule of Benefits; and 4. Are not otherwise excluded under this Policy. Altern.tive Care In addi ion to satisfying Eligible Expenses criteria 2, 3 and 4 above,expenses related to Alternative Care ay be considr red Eligible Expenses when all of the following additional criteria have been satisfied: 1. You demonstrate to Our satisfaction that providing the Alternative Care resulted in a cost savings to th Plan; and 2. The Alternative Care was recommended by case management services provided to Your Plan;and 3. The Alternative Care was Medically Necessary and Appropriate; and 4. The Alternative Care was provided with the consent of the Covered Person,or his/her representative,and with the approval of the Covered Person's licensed health care provider, and was approved by You or Your TPA;and 5. The Alternative Care replaces Treatment that would be covered under Your Plan;and 6. The Alternative Care expenses do not exceed the maximum allowed under Your Plan for the Treatment replaced by the Alternative Care; and 7. If the Alternative Care is provided in lieu of inpatient hospitalization,the Covered Person meets utilization review criteria acceptable to Us for inpatient hospitalization for the entire period the, Alternative Care is provided. In no event will such Alternative Care that exceeds 90 days be consi ered Eligible Expenses unless approved by Us. Off-L..bel Drug Use In add tion to satisfying the criteria for Eligible Expenses set forth above,expenses related to Off-Label D g Use may b; considered Eligible Expenses when all of the following additional criteria have been satisfied: 1. The drug is not excluded under Your Plan; and 2. The drug has been approved by the FDA; and 3. You can demonstrate to Our satisfaction that the Off-Label Drug Use is appropriate and generally accepted for the condition being treated;and 4. If the drug is used for the treatment of cancer,the American Medical Association Drug Evaluatio s,The American Hospital Formulary Service Drug Information, or The Compendia-Based Drug Bulletin. recognize it as an appropriate treatment for that form of cancer. Reim I ursement of Certain Fees Eligib e Expenses will also include the following fees Incurred and Paid by You,when approved by Us at Our U.S. eadquarters: 1. Reasonable hourly fees for case management services provided by a registered nurse case manage retained by You or Your TPA;and 2. Fees for: (a)hospital bill audits; (b)access to non-directed provider networks; and(c)negotiating out of network bills. Such -es shall be considered Eligible Expenses only if You can demonstrate to Us that the work which g-nerated the fe:s resulted in a cost savings to the Plan.If the Plan can demonstrate such a cost savings,We will rei burse You u o to 25%of the amount saved. Fees c arged by Your TPA or any subsidiary of Your TPA for any of these services will be considered Eligible Expen.es only if prior approval has been obtained in writing from Us at Our U.S.Headquarters. 02-SL 6 • Section II Benefit Provisions Expenses Eligible for Reimbursement State ealth Care Surcharges If You say a state health care surcharge imposed by Louisiana,Massachusetts or New York in connection with the pa ent of Eligible Expenses,such health care surcharges are included as Eligible Expenses.We will only reimbu se health care surcharges imposed by New York if You are registered with the New York Departm-nt of Health. 02-SL 7 I Section II Benefit Provisions Limitations and Exclusions We will NOT reimburse You for: 1. Ex enses for medical services rendered to a Covered Person by the Covered Person's family member or rel tive. 2. Ex enses relating to an injury or illness arising out of,or occurring during the course of,a Covered Person pe orming any occupation for wage or profit. 3. Ex enses for any cosmetic Treatment as defined in Your Plan.This exclusion does not apply to expenses rel ting to breast reconstruction after mastectomy. 4. Ex enses for any Experimental or Investigational Treatment,or for any hospital confinement or Treatment th. results from Experimental or Investigational Treatment. 5. Ex.enses for any transplant not included in the definition of Transplant. 6. ' Ex senses relating to non-human organ or tissue transplants,gene therapies,xenographs or cloning., 7. Ex o enses for any Treatment administered outside the United States if the Covered Person traveled to the to.ation where the Treatment was received for the purpose of obtaining the Treatment. I 8. Ex 8 enses for benefits in excess of Your Plan's limits, or expenses that are excluded under Your Plan. 9. Ex senses in excess of the Usual and Customary Fee. 10. ' y amount paid by You in excess of a negotiated provider discount,or any penalty or late charge incurred, or :ny discount lost,unless previously approved in writing by Us at Our U.S.Headquarters. 11. Ex 8 enses associated with the administration of Your Plan including,but not limited to,claim paymen fees, co t containment administrative fees,PDP administration fees,PPO access fees,premium functions, edical re iew and consultant fees,unless otherwise covered under this Policy. 12. E lenses paid by You relating to any litigation concerning Your Plan,including,but not limited to, at orneys' fe:s,extra-contractual damages,compensatory damages and punitive damages. 13. , I y portion of an expense which You are not obligated to pay under Your Plan,or which is reimburs.ble to You under: a) another group health benefit program;or b) a government or privately supported medical research program; or c) Medicare;or d) any coordination of benefits or non-duplication of benefits provision of Your Plan; or e) worker's compensation; or f) any other source. 14. E its enses for claims submitted to Us that are not submitted in accordance with the Proof of Claim pro isions of his Policy. 15. E ipenses incurred by a person who is employed by You at any unit,subsidiary or division of Yours that has no been underwritten by Us. I 16. E ipenses incurred for any illness or injury due to,or aggravated by,war or an act of war,whether deo ared or un o eclared. 1 1 02-SL 8 • Section II Benefit Provisions Limitations and Exclusions 17. If our Plan does not exclude coverage for conditions for which a Covered Person received Treatment within 6 onths prior to enrolling in Your Plan, expenses for any such condition will be excluded from rei bursement under this Policy for a period of twelve(12)months from the Covered Person's effective date un•er Your Plan(the"12 month period").The 12 month period will be reduced on a month for month basis by any"creditable coverage"(as defined in the Health Insurance Portability and Accountability Act of 1996, as .mended)attributable to the Covered Person. 18; E .enses paid by You for any Treatment authorized or approved under any provision of Your Plan w ich: a) allows the plan administrator to approve alternative care or alternative treatment; or b) allows the plan administrator to alter,modify,or waive Plan provisions or limitations; or c) grants You or Your plan administrator discretion to approve coverage for Treatment not othe ise covered under Your Plan; un ess the Treatment satisfies the criteria for Alternative Care set forth in Section II. 19. E is enses covered under a Prescription Drug Plan,unless Prescription Drug Plan coverage is a Covered B:nefit on the Schedule of Benefits. 20. E Ipenses for Treatment of Mental Illness and Drug or Alcohol Dependence will be limited to the less•r of Your Plan's maximum benefit for any such condition or the Specific Benefit Deductible. 02-SL 9 Section III Claim Provisions Proof i f Claim Proof•f claim must be provided to Us at Our U.S.Headquarters. Specif c Benefit W 'tten proof of claim,in a form and content satisfactory to Us,must be provided to Us as soon as rea.onably ' po.sible after the Specific Benefit Deductible for a Covered Person has been satisfied.Proof of claim ust be provided to Us no later than 12 months after the end of the Specific Benefit Claims Basis during whic the cl.c arose. Proof of claim for a Specific Benefit claim shall include the following: 1. a fully completed claim form; 2. a copy of the Covered Person's original enrollment record and records of any change in the Covered Person's coverage under Your Plan; 3. copies of all bills and invoices for expenses submitted for reimbursement under this Policy; 4. proof of payment of any expenses submitted to Us for reimbursement under this Policy; and 5. any additional information We may require to fulfill Our obligations under this Policy. Aggregate Benefit W 'tten proof of claim,in a form and content satisfactory to Us,must be provided to Us as soon as reaisonably po.sible after the end of the Aggregate Benefit Claims Basis for the Policy Year.Proof of claim must e pro vided to Us no later than twelve(12)months after the end of the Aggregate Benefit Claims Basis. Pro of of claim for an Aggregate Benefit claim shall include the following: • 1. a complete aggregate calculation report; 2. a detailed claims history report for all Eligible Expenses Incurred and Paid during the Aggreg to Benefit Claims Basis; 3. a report listing all Covered Units eligible for benefits under Your Plan at any time during the Aggregate Benefit Claims Basis; 4. a copy of Your Plan in effect during the Policy Year and any amendments thereto; 5. if Prescription Drug Plan coverage is included as a Covered Benefit on the Schedule of Benefits, a copy of all prescription drug invoices and an itemization thereof,including the amounts of any rebates received by You; and 6. any additional information We may require to fulfill Our obligations under this Policy. Appe.1 of a Claim Determination You ay appeal any claim determination made by Us under this Policy by submitting a written appeal to Us at Our U S.Headquarters within sixty(60)days from the date of Our determination.Your appeal should state the basis •f Your disagreement with Our determination and should include all documentation and information suppo t ing Your appeal that has not been previously provided to Us. An ap heal of any claim determination made by Us on the grounds that the Treatment provided was: (a)no I Medically Necessary and Appropriate; (b)cosmetic;or(c)Experimental or Investigational must ' dude an Independent Review Panel report which includes each panel member's report and the panel's conse s sus report.The Independent Review Panel report is to be provided at Your expense.The members f the Indep=ndent Review Panel must be mutually acceptable to You and Us. Defer ed Payments by You You ust obtain prior written approval from Us at Our U. S.Headquarters in order for any Eligible Expe ses Incurr''d in the Policy Year,but Paid after the end of the applicable claims basis to be considered eligible for reimb rsement under this Policy. 02-SL 10 Section III Claim Provisions Paym•nt of Claims All be"efits due under this Policy will be paid to You.During the Policy Year,reimbursements will be dis•ursed when t e amount payable exceeds$500.00.Any reimbursable amount remaining unpaid at the end of a P•hey Year ill be paid after the end of the Policy Year. 02-SL 11 . I Section IV Your Rights and Responsibilities • Authorizations to Release Information You are responsible for authorizing Your TPA,Plan Administrator,case manager or other third party serv'_ce provid r to release to Us information We request to underwrite,review potential claims,make claim dete 'nations,calculate potential reimbursements, or perform other obligations under this Policy.If We do not receiv requested information,it may result in the delay,reduction or denial of a claim. Disclo ure Requirements This P licy has been underwritten based upon the information You provided to Us concerning all persons eligible for be efits under Your Plan on the Original Specific Benefit Effective Date and/or the Original Aggregat Benefi Effective Date(or on the effective date of any class of Covered Persons added thereafter).This in Ludes, but is ii of limited to,those persons who are a special risk as defined in the Special Risk Questionnaire. Your .gnature on the Application for this policy warrants and represents to Us that: 1. You or Your authorized representative have consulted with Your precertification,utilization revie and Medical Management Vendors and Your TPA, or former TPA,to determine who must be disclosed as a special risk on the Special Risk Questionnaire;and 2. You have identified any person who is or maybe a special risk by either listing them on the Speci 1 Risk Questionnaire or by indicating any such person on the reports listed on the Special Risk Questionnaire. If You fail to disclose an individual as a special risk,who should have been disclosed as a special risk in accor8.1 ce with the Special Risk Questionnaire,We will have the right to revise the premium rates, deductibles, deductible factors and terms and conditions of this Policy in accordance with Our underwriting practices i effect at'the ime the Policy was underwritten,retroactive to the Original Specific Benefit Effective Date and/or he Origin 1 Aggregate Benefit Effective Date. Reporting Requirements You e required to provide periodic reports to Us as described below.If You, or Your TPA,do not provi e the report ,or do not provide them on a timely basis,We reserve the right,once We receive them,to take wh.tever action e could have taken if the reports had been provided when required. Such action may include,but is not limite to,the right to revise premium rates,deductibles, and deductible factors,and to do so retroactive to the Origin 1 Specific Benefit Effective Date and/or the Original Aggregate Benefit Effective Date. Speci c Benefit Reporting Y u, or Your TPA, are required to provide Us with notice of any potential Specific Benefit claim wit in th y-one(31) days of the date: 1. a Covered Person's Eligible Expenses exceed 50%of the Specific Benefit Deductible; or 2. You,Your TPA,or Your medical management,utilization review or precertification vendors, or any other party acting on Your behalf,are notified that a Covered Person has been diagnosed with,or treated for,a Catastrophic Diagnosis. Aggre ate Benefit Reporting You,or Your TPA,are required to provide Us with a monthly report that lists: 1. the total amount of Eligible Expenses Incurred by any Covered Person and Paid by You,or P.id on Your behalf,during the Benefit Month; and 2. the number of each type of Covered Unit on the first day of the Benefit Month. You must provide the Aggregate Benefit report to Us within thirty-one(31) days after the end of eac Benefit Month. 02-SL 12 Section IV Your Rights and Responsibilities Renew.1 Reporting If ' ou intend to renew this Policy,then three months prior to the end of the Policy Year,You,or Yo TPA, ar:required to provide Us with a report which includes the following information: 1. monthly Paid claims and enrollment data,organized by Covered Benefit; 2. large claim information,including amount,diagnosis and prognosis,and any Covered Person who has been diagnosed with a Catastrophic Diagnosis; 3. a census of all Covered Persons; 4. a summary of the number of Covered Persons by workplace zip code,if this Policy covers E ployees at multiple locations; 5. a summary report of precertification,utilization review and case management services; 6. a summary report of Your Provider Network(s)or per diem arrangements, setting forth the av rage hospital discount or per diem charge per day; and 7. a copy of changes adopted by or proposed for Your Plan. Plan I hanges You st notify Us in writing at Our U. S.Headquarters at least thirty-one(31)days before the effective •ate of any ch nge in, or to: 1. Your Plan; 2. Your TPA; I 3. Your Provider Networks;or 4. Your Medical Management Vendors. Our p or written agreement is required before the coverage under this Policy will apply to any such chan e. Othe ise,benefits under this Policy will be paid based upon the terms of Your Plan as it existed prior to ny such c ange.We reserve the right to terminate this Policy as of the effective date of any change in or to Y ur Plan, our TPA,Your Provider Network,or Your Medical Management Vendor. N'otic:of Legal Action You a:a ee to give Us prompt notice of: (a)any event that might result in a lawsuit relating to this Policy; r(b) any la suit involving this Policy; and to promptly provide Us with copies of any correspondence and ple dings relatin:to any such event or lawsuit. Hold armless You a: ee to defend,indemnify and hold Us harmless from and against any and all claims, demands and auses of action of every kind,relating to any litigation,that We,without Our fault,become involved with that relat s to this P•licy or Your Plan.You shall pay any and all attorneys' fees, costs,expenses,and damages(includi g comp: satory,exemplary or punitive damages)incurred by Us, or payable by Us, in connection with any uch litigation.This Hold Harmless provision shall not apply to litigation solely between You and Us relating t this Policy Refun I of Overpayment If We,You,or Your TPA determine that We have overpaid You under this Policy,You will promptly re d such overpayment to Us within 60 days of such a determination. If We are required to take legal action to colle t such overp.yment,You agree to indemnify Us for any costs of collection,including,but not limited to, attome s fees and c• costs. Respo sibility For Your TPA You a e solely responsible for the actions of Your Plan Administrator,Your TPA and any other agent of Yours. Your PA acts on Your behalf,not on Our behalf.Your TPA is not Our agent.We are not responsible for any comp:nsation owed to,or claimed by,Your TPA or other agents for services provided to,or on behalf of,Your Plan. his Policy does not make Us a party to any agreement between You and Your TPA,nor does it make Your TPA . party to this Policy. 02-SL 13 Section IV Your Rights and Responsibilities Right f Recovery You st pursue all valid claims including,but not necessarily limited to,claims for restitution,constructive trust, -quitable lien,breach of contract,injunction,and any other state or federal law claims You or Your Flan may h.ve against any third party responsible,in whole or in part,for any Eligible Expenses Paid by You.You must i i ediately advise Us of any amount You recover from them.We reserve the right to pursue any . d all such c aims not pursued by You,and You agree to assign such claims to Us upon Our request. 02-SL 14 Section V Our Rights and Responsibilities Audit We have the right to inspect and audit any and all of Your records and procedures,and those of Your TPA and any ot_ier party,that relate to any claim made by You under this Policy.We have the right to require documentation from You that demonstrates You paid an Eligible Expense and that the payment was made in accor lance with the terms of Your Plan.We reserve the right to employ a third party, at Our expense,to a.sist Us with y audit function. Deter ination of Eligible Expenses For th purpose of determining Eligible Expenses under this Policy,We have the right to determine whether an expen e was Paid by You in accordance with the terms of Your Plan. Cost ontainment We h. e the right to retain the services of a Medical Management Vendor, at Our expense,to assist Us with cost contai ent when We anticipate that a Covered Person's Eligible Expenses will exceed 50%of the Specific Benef t Deductible during the Policy Year. Confi entiality We w' 1 protect the privacy and confidentiality of all personally identifiable and/or medical information provided to Us 'n the course of underwriting or administering this Policy in accordance with Our policies and applibable state . d federal laws. Reco pment We h. e the right to recoup from any benefit payable to You under this Policy any premium You owe to Us that has no been paid. Our right of recoupment does not impair Our right to terminate this Policy for non-pay ent of pr;emi m under the Termination Provisions of this Policy. Right to Recalculate We h. e the right to recalculate any Specific Benefit Premium Rate, Specific Benefit Deductible,Aggieg ting Speci'lc Deductible,Aggregate Benefit Premium Rate,Aggregate Deductible Factor or Minimum Aggre ate Dedu• ible with respect to this Policy Year whenever any one or more of the following events occur: 1. Your Plan changes; 2. You change Your TPA,Your Provider Network(s),or Medical Management Vendor(s); 3. this Policy is amended; 4. the number of Covered Units on the first day of a Benefit Month increases or decreases by more t an 15% from the number of Covered Units on the first day of the Policy Year; 5. the number of Covered Units on the first day of a Benefit Month increases or decreases by more t an 10% from the first day of the prior Benefit Month; 6. a unit,division,subsidiary, or affiliated company of Yours is added to,or deleted from,this Policy; 7. the amount of Eligible Expenses paid in any one of the three(3)months immediately preceding the Policy Effective Date(the"three month period")exceeds 125%of the monthly average of Eligible Expe ses Incurred during the nine(9)months immediately preceding the three month period; or 8. there are changes in Your, or Your TPA's,claim paying system or payment practices that causes variation of fifteen(15)days or more in the most recent twelve(12)month average of claim proc ssing time. Any 'ght to recalculate exercised under this section may be made retroactive to the Policy Effective Date at Our election.Any recalculation will be made in accordance with Our underwriting practices in effect at the time the Polic was underwritten.The right to recalculate shall survive the termination of this Policy. 02-SL 15 Section V Our Rights and Responsibilities Right i f Reimbursement Any p•rtion of an Eligible Expense which You recover from a third party: 1. is not eligible for reimbursement under this Policy; and • 2. cannot be used to satisfy any deductible or attachment point under this Policy;and 3. must be repaid to Us if We previously reimbursed You for it. Any re•ayment amount You owe Us may be reduced,with Our consent,by any reasonable and necessary expens•s You incurred in obtaining the recovery from the third party.Any repayment amount You owe to Us shall s ive the termination of this Policy. 02-SL 16 Section VI General Provisions Assig ment Your• terest in this Policy cannot be assigned. Ban uptcy or Insolvency The b nkruptcy,insolvency,dissolution,receivership or liquidation of You,Your Plan or Your TPA will not impos upon Us any obligations other than those set forth in this Policy. Cleri al Error In the vent of a clerical error in this Policy,the Policy will be revised to correct the error.Your failure to ' 1. report the existence of a Covered Person; or 2. file proof of claim in a timely manner;or 3. comply with the reporting requirements of this Policy; shall of constitute clerical error. Entir Contract This olicy,along with any Attachments,Riders,Endorsements or Amendments, and the Application an Special Risk uestionnaire completed by You constitutes the entire contract of insurance between Us. Legal Action You ay not bring a legal action against Us to recover on this Policy earlier than sixty(60)days after Yo have fiurnis ed Us with proof of claim in accordance with the Proof of Claim provisions of this Policy.You ma 'not bring ny legal action against Us to recover on this Policy after two(2)years from the time proof of clairri is requir d under this Policy. Misre a resentation If: 1. You make any misstatement, omission or misrepresentation,whether intentional or unintentional,in the information or documentation You,Your TPA or any other party acting on Your behalf,provide o Us, and which We rely upon during the underwriting of this Policy; or 2. after this Policy is issued,We learn of expenses or claims that were incurred or paid,but not repo ed to Us,during the underwriting of this Policy; We h.ve the right,at Our election,to rescind this Policy or to revise the premium rates,deductibles, and terms and c a nditions of this Policy in accordance with Our underwriting practices in effect at the time the Polic I was unde itten.Any such revisions may be made retroactive to the Policy Effective Date. No E t SA Liability Unde no circumstance will We accept responsibility as a"Plan Administrator"or be deemed a"plan fid ciary" with r•spect to Your Plan under the Employee Retirement Income Security Act of 1974,as amended. Non-'articipating Policy This 'olicy is non-participating and does not share in Our surplus earnings. Polic Amendment No ch:nge in this Policy,or waiver of any of its provisions,will be valid unless such change or waiver is n writing and agreed to by Us at Our U. S.Headquarters and made a part of this Policy.No agent,broker,T'A, or managing general underwriter has authority to change this Policy or waive any of its provisions. Polic Renewal This 'olicy may be renewed on the Policy Anniversary Date unless it has been terminated or is subject to te ' ation in accordance with the Termination Provisions of this Policy.Policy changes for any renewal policy will a pear on a revised Schedule of Benefits and/or a Policy amendment. Your payment of the renewal premium after r ceipt of the revised Schedule of Benefits and/or Policy amendment constitutes acceptance of the renewal policy by You. 02-SL 17 Section VI General Provisions � I Premi m Provisions Premi m Payments Pr,mium is due on or before the Premium Due Date. Grace 'eriod A i ace period of thirty-one(31)days will be allowed for the payment of each premium due after the first premium has been paid.This Policy will continue in force during the grace period.If a premium is no I paid by the end of the Grace Period,this Policy will terminate,without notice to You, as of the last date for w a ich premium was paid. Premi m Data Y•u must provide a report to Us with each premium payment,in a form satisfactory to Us,that lists: 1. the number of each type of Covered Unit,for each Covered Benefit,under Your Plan on the rst day of the Benefit Month; and - 2. the amount of premium paid. W- use such premium data reports solely to process premium. They do not replace any report require.,or w ich may be required,under Section IV of this Policy. Sever bility In'the -vent that any provision of this Policy is invalidated by a court of competent jurisdiction,all remai i ng provis ons of the Policy shall continue in full force and effect. Terml ation Provisions 1. If You fail to pay the premium,this Policy will terminate in accordance with the Premium Provisi on of this Policy. 2. If Your Plan is terminated,this Policy will terminate on the date the Plan terminated. 3. If You fail to maintain a minimum of 150 participants in Your Plan at any time during the Policy ear, We may elect to terminate this Policy at the end of the first month during which there are less tha 150 participants. 4. This Policy will terminate at the end of the Policy Year unless renewed. 5. If You,or Your TPA,fail to satisfy any of Your obligations under this Policy,We may terminate his Policy by giving You sixty(60)days advance written notice. 6. We may terminate this Policy within thirty-one(31)days of the end of the Policy Year. 7. You may terminate.this Policy at any time by providing Us with 90 days advance written notice a Our U. S.Headquarters. The p. ies to this Policy may agree in writing to terminate it at any time. Reins atement If this I'olicy is terminated for non-payment of premium,We may,at Our sole discretion, agree to reinstate it as of the da le it terminated upon payment of all outstanding premium.We may require You to provide certain info ation to Us before We will consider reinstating the Policy. Time I.Amitations If any lime limitation in this Policy is less than that permitted by the law of the state in which the Applica lion was taken,the limitation is hereby extended to the minimum period permitted by the law. 02-SL 18 Sun Life Assurance Company of Canada SunExcel® Transplant Benefit Rider Effecti e January 1,2005,this Rider is attached to and made part of Stop-Loss Policy No. 69026 issued by Sun Life A surance Company of Canada(the"Policy"). Intro'uction T e SunExcel®Transplant Benefit provides a number of benefits,which include: providing Covered Persons with access to Centers of Excellence Transplant Facilities; reducing the Specific Benefit Deductible for a Covered Person who uses a Centers of Excellenc Transplant Facility for a Transplant; payment of the transplant network access fee; reimbursement for travel and lodging expenses incurred by a Covered Person immediately prior to,and following,a Transplant if such expenses are covered under Your Plan; and reimbursement for certain expenses and deductibles paid by the Policyholder. Defini ions Al capitalized terms used in this Rider shall have the meaning attributed to them by the Policy.For t pu .ose of this Rider,the following term shall be defined as follows: Centers of Excellence Transplant Facility: A Transplant Facility We have contracted with as p.rt of the SunExcel®program. Requi ements To qu.lify for the SunExcel®Transplant Benefit,You and Your Plan must satisfy all of the following requir;ments: 1. Your Plan must: a) require precertification for Transplant related hospitalizations and outpatient Transplant procedures; b) offer a minimum Transplant benefit of$300,000.00; c) treat Centers of Excellence Transplant Facilities as in-network providers; and 2. You must: a) amend Your Plan to include the SunExcel®Transplant Benefits listed in section 3 and 4 below; b) require Your TPA and Provider Network(s)to permit Covered Persons to access SunExcel® i enters of Excellence Transplant Facilities; c) advise Your TPA and Medical Management Vendor(s)that Covered Persons may access Cen ers of Excellence Transplant Facilities,and instruct Your TPA and Medical Management Vendor(s)to contact Us at 1-888-4ORGANS when they receive notice that a Covered Person may require a Transplant; d) advise Covered Persons that they may access Centers of Excellence Transplant Facilities if they need a Transplant;and e) agree to waive any exclusion under Your Plan that excludes expenses relating to the acquisiticp n of an organ for a Transplant("organ acquisition expenses"),when organ acquisition expenses are included in the global fee negotiated with a Centers of Excellence Transplant Facility. 02-SL-.TBR • Sun Life Assurance Company of Canada SunExcel® Transplant Benefit Rider SinE cel®Transplant Benefit If You satisfy the requirements set forth above,and a Covered Person has a Transplant performed at a Centers of Excell-nce Transplant Facility,We will: 1. reduce the Specific Benefit Deductible for the Covered Person by$10,000 for the Policy Year in which the Transplant occurs;and 2. pay any fee required for access to the Centers of Excellence Transplant Facility. In add' ion,if Your Plan provides the following benefits as covered benefits under the SunExcel®Transpl.nt Benefi ,Eligible Expenses will include: 3. up to$5,000.00 for any travel and lodging expenses incurred by the Covered Person and one comp anion immediately prior to,and following,the Transplant;and/or 4. up to$1,500.00 for any deductible and co-payments waived by,or paid to,the Covered Person Iby Your Plan,for the year in which the Transplant occurs. President Secretary 02-SL-.TBR • I Sun Life Assurance Company of Canada Endorsement This Efdorsement is made part of the Policy to which it is attached. I. The Transplant Definition in Section I,"Definitions,"is deleted and replaced by the following: Transplant: The transplant of organs from human to human,including bone marrow, stem cell a d cord blood transplants.Transplants include only those transplants that: (a)are approved for Medicare coverage on the date the Transplant is performed; and(b)are not otherwise excluded by this Policy. A Transplant must be performed at a Transplant Facility to be considered for reimbursement unde this Policy. Skin and cornea transplants are not considered a transplant for the purpose of determining I ligible Expenses under this Policy,but are considered Eligible Expenses if covered by Your Plan. II. Item 17 in Section II,"Benefit Provisions—Limitations and Exclusions,"is deleted. Effective Date: January 1,2005 President Secretary ` I 02-SL-3ND-1 Sun Life Assurance Company of Canada Endorsement This E dorsement is made part of the Policy to which it is attached. Item 2 in Section II,"Benefit Provisions-Limitations and Exclusions,"is deleted and replaced by the following: 2. Expenses that are payable or reimbursable under any Workers' Compensation Law or similar legislation. Effecti e Date: January 1,2005 'I'{IV.q President Secretary 1 02-SL- ND-2 I � Sun Life Assurance Company of Canada Amendment No. 1 This • endment is attached to and made part of Stop-Loss Policy No. 69026 issued by Sun Life Assuran,e • Comp.ny of Canada(the"Policy"). Effect' e January 1,2005,retirees will not be included as Covered Persons under this Policy,except fort ose retiree. as stated in Appendix A[Appendix A attached]. 41: ut.44..A.„ President, Secretary I � I � I i II 02-SL •MEND CITY OF RENTON I STANDARD CENSUS 8/25/2004 Enrollee Enrollee Enrollee Spouse Dependent Zip Code Name Sex Age Age Age Location RE8B ADAMS "R m 61 0 0 85375 ANTHO ,Y R m 66 0 0 99352 BAKKO , m 61 0 0 98022 BINGAM A N TG m 72 0 0 98055-1613 BOURA'A JH m 67 0 0 98365 BRONS:MA WH m 59 0 0 92071-3854 BUFF J: m 72 0 0 98056 CALDW'.LL H m 67 0 0 85375 CONKLI GH m 62 0 0 98059 COOPE" FJ m 79 0 0 98584 DARBY R m 80 0 0 98592 DRIGGE-S MR m 52 0 0 98042 EVANS R m 67 0 0 98038-8849 FASSET WR m 61 0 0 98555-0065 FERGU"ON SH m 58 0 0 98557 FILE WI m 65 0 0 98292 FOUST T m 64 0 0 98032 GIBSON�JM m 60 0 0 98024 GLENN D m 62 0 0 98056 HAJNY JJ m 60 0 0 98840 HALLO m 67 0 0 98059 HEITZ N f 58 0 0 97420 HUBNE AJ m 72 0 0 98303 HUME L m 73 0 0 98277 ILES KL f 55 0 0 98109-1214 KITTEL ON GR m 61 0 0 98353 LAPHA JP m 60 0 0 96753 LEYERL RL m 69 0 0 99206 LINDBE G DE m 61 0 0 98056 LOPEZ 1M m 55 0 0 99801 MACULA MJ m 58 0 0 85739 MATHIA ON RD m 61 0 0 98837 MECHA RL m 61 0 0 98056 NIBARG R R m 68 0 0 98922 NORRIS C m 65 0 0 98188 OLSON ''A m 52 0 0 59834 ' ORR D m 72 0 0 96740 OWEN A m 60 0 , 0 98010 ' PAVON: JC m 64 0 0 98055 PHELAN JE m 68 0 0 98056 RITCHI: G m 64 0 0 98837 1 I SAUDE A m 69 0 0 98055 SMITH D m 63 0 0 40403 STODD RD RA m 60 0 0 98532 SUNDV LL J m 65 0 0 98058 ' TOFTHA EN BA m 67 0 0 98059-3326 TOMAN M m 57 0 0 98038 TREAD ELL TL m 51 0 0 98922 VAUGH R m 60 0 0 98056 d Location RE8D GERBE- DE m 48 0 0 98038 PEACH W m 56 0 0 98045 PERSS•N DR m 62 0 0 98055' SEELYE RA m 52 0 0 98058 Location RE9C ANKEN CD m 66 0 0 98031 BALES RASSE R, m 63 0 0 98024 BANAS I GC m 81 0 0 98055 BARILL:AUX RC m 68 0 0 98056 CHRIST: NSON CD m 63 0 0 98056-2610 CODIGA L m 58 0 0 98555 COLOM::I JL m 72 0 0 98056 CONNE L RL m 83 0 0 98178-3976 DAWKINS G m 55 0 0 97424 GEISSL:R R m 75 0 0 98056 GOOD IN D m 82 0 0 98382 GOOD IN JR m 72 0 0 98225-8190 GORDO GG m 63 0 0 98056 GOT;TI c D m 60 0 0 98829 HENRY J m 78 0 0 98056 HUNT H m 61 0 0 98922 H U RIST 1 A m 83 0 0 86403 JONES 4. m 70 0 0 98001 LARSO WH i m 68 0 0 98055 LAVALL:Y T m 67 0 - 0 98056 MATTH:W J F m 61 0 0 98059-3817 MAUK JD m 54 0 0 98903 MCLAU t HLIN JJ m 62 0 0 98524 NEWTO G m 65 0 0 98056 NEWTO RJ m 61 0 0 98056 NICHOL• GH m 70 0 0 98498-5643 PEDER-EN KN m 62 0 0 98579 PHILLIP. BH m 74 0 0 98059-8123 PILLO R m 57 0 0 98056 - PRICE '',D m 59 0 0 86426 PRINGL AJ m 76 0 0 98827 RICHARDSON C m 51 0 0 98146 RIGGLE E m 61 0 0 98261 RUPPRECHT J m 61 0 0 98031-8642 SCHNEIDDERSJ m 60 0 0 98346-9169 SMITH L m 72 0 0 98092-8013 STEEL m 56 0 0 98031 THORS s N DM m 61 0 0 98059 TODD F m 77 0 0 78628 • TON®A ; J m 81 0 0 98056 VACCA A m 63 0 0 98055-5917 WALLS m 61 0 0 98038 WALSH IIC m 79 0 0 98056 WALSH 'J m 83 0 0 98056 WEISS R m 59 0 0 85374 Grand T•tals Total Enrollees: 96 Total Spouses: 0 Total Members: 0 ' I 1 I Terri L Shuhart- Fw: City of Renton: Stop Loss Contract Pale-N1 From: "Pamela Arwood" <pamela@charlesgroup.net> To: "Terri Shuhart" <Tshuhart@ci.renton.wa.us> Date: 3/14/2005 3:48:03 PM Subject: Fw: City of Renton: Stop Loss Contract Terri, Here is the response (with attachment) on the retiree coverage question on the Sin Life contract. Tony is still working on your other question :) Pamela riginal Message From: <tony.sepanski@sunlife.com> To: < amela@charlesgroup.net> Sent: Monday, March 14, 2005 3:37 PM Subje t: Re: City of Renton: Stop Loss Contract >' > > Hi amela: > >.I hal e an answer for you on question#1 --the contract amendment#1 says > the retirees covered prior to January 1, 2005 will continue to be covered. >:It s unds like you didn't receive the attachment(Appendix A) that was > sup osed to go with it-- I've attached it here, it's a list of the > reti ee > tha we are covering: >. > (Se attached file: Appendix A for Policy#69026.xls) > Thi is actually part of the contract as well. > I shpuld have an answer regarding the administration of the reimbursements > soon. >' >Th nks much for you patience--let me know if you have any Q's. > . > Sin erely, > , > To y Sepanski >,Ac ount Manager > Su Life Financial > >' >,---- Forwarded by Tony Sepanski/Group/US/SunLife on 03/14/2005 03:31 PM >---- ' > > Tony Sepanski To: "Pamela Arwood" >;<p mela@charlesgroup.net> > 03/11/2005 08:41 AM cc: Subject: Re: City of Renton: > Stop Loss Contract(Document link: Tony Sepanski) > (-Terri L Shuhart- Fw: City of Renton: Stop Loss Contract Page ..r. > > Hi -amela: >'I ju-t wanted to drop you a quick email to tell you that I am working on > getting answers to your inquiries. I just don't have it yet but I wanted >you to know I have been working on it. As soon as I find out I'll send >you > an -mail asap. Thanks much for your patience; you'll be hearing from me >.soo . > Th-nks, >To y > 1 > "Pamela Arwood" To: "Tony Sepanski" > <to y.sepanski@sunlife.com>, "Terri Shuhart" > <pamela@charlesgroup.net> <Tshuhart@ci.renton.wa.us> > 03/09/2005 06:49 PM cc: > Subject: City of Renton: >,Sto. Loss Contract > >, > >'To y, >,Hi! Here is the e-mail that I mentioned in a voice message to >yo >yes erday regarding some questions on the City of Renton's Stop > Lo s > Co tract with Sun Life. The City reviewed the contract and wanted > to >ver fy the following: > 1) Schedule of Benefits: states that Retirees are"Not Covered", >yet >the e is a group of Leoff I Retirees as stated on their"Application >;for > Stop Loss" states there is coverage for Retirees (a "closed group > of > reti ees"). Amendment, or reissue? > 2) Section III. Claims Provisions: Are we correct that if Sun > ha > rei bursement totaling under$500 during a Plan Year that the funds will • be > hel• until the end of the Plan Year, and then reimbursed? >,Th.:nks for answering these quick questions. TerriyL Shuhart- Fw City of Renton: Stop Loss Contract _ _ ____ Page.__, ' • >'Pa ela J. >!Arw•od >The Charles Group, >I825' 165th Ave >1NE >.Re•mond, WA 98052 > >1Tel: >'425 861-5885 >IFa c 425-885-6302 >, >1 >, >'Thi'. e-mail message (including attachments, if any) is intended for the >I us- >of t e individual or entity to which it is addressed and may contain >j inf•rmation that is privileged, proprietary , confidential and exempt from >,dis,losure. If you are not the intended recipient, you are notified that >I an dissemination, distribution or copying of this communication is >,stri i tly prohibited. If you have received this communication in error, >I ple.:se notify the sender and erase this e-mail message immediately. >, 141.0111 I I " I • I it Sun Life Assurance Company of Canada STOP-LOSS POLICY Policyh I)Ider: City of Renton Policy 'umber: 69026 Policy :ffective Date: January 1,2005 Policy 'enewal Effective Date: January 1,2006 This Po icy is delivered in Washington and is subject to the laws of that jurisdiction. Sun Lit'. Assurance Company of Canada agrees to pay the benefits provided by this Policy in accordance with the provisi ins contained herein.This Policy is issued in consideration of the Application submitted by the Policyholder,a copy of which is attached,and continued payment of premium by the Policyholder.The Applic. ion,Special Risk Questionnaire,and any Riders,Endorsements and Amendments to this Policy ar made part of d 's Policy. The Po cyholder will hereafter be referred to as"You,""Your,"and"Yours." � I Sun Li - Assurance Company of Canada will hereafter be referred to as"We,""Our"and"Us." When •etermining any date under this Policy,all days begin at 12:00:00 a.m,and end at 11:59:59 p.m.st. dard time fo Your headquarters. Signjled.t Our U.S.headquarters,One-Sun Life Executive Park,Wellesley Hills,Massachusetts,by: al\ 4:4 11 ti President Secretary PLEASE READ YOUR POLICY CAREFULLY Non-Participating This i• a reimbursement policy.You,or Your Plan administrator,are responsible for making bene t deter' inations under Your Plan.We have no duty or authority to administer,settle,adjust or provide advic=regarding claims filed under Your Plan. ,n dl.44� ie„i Sun Life Assurance Company of Canada'is a member of the Sun Life Financial group of companies. Sun� ♦�� ©2002 S n Life Assurance Company of Canada,Wellesley Hills,MA 02481.All rights reserved. Life Financial 02-SL it III Table of Contents Section Description Page Schedule of Benefits iii I Definitions 1 II Benefit Provisions 4 • Specific Benefit 4 • Aggregate Benefit 5 • Eligible Expenses 6 • Limitations and Exclusions 8 III' Claim Provisions 10 IV Your Rights and Responsibilities 12 V Our Rights and Responsibilities 15 I I VI General Provisions 17 h � • Premium Provisions 18 • Termination Provisions 18 ,;I I I i I° I 02-SL ii Schedule of Benefits Specific Benefit Origina Specific Benefit Effective Date January 1,2005 1. Benefit S•ecifications Renew.1 Policy Year January 1,2006 through December 31,2006 Remb rsement Percentage 100%of Eligible Expenses Covere,' Benefits Medical Prescription Drug Plan(PDP) Specifi, Benefit Deductible $150,000 Specifi, Benefit Lifetime Maxim m Reimbursement $850,000 Specifi, Benefit Claims Basis Paid Eligible Expenses include only those expenses Incurred a er January 1,2004 and Paid during the Policy Year. Couere s Unit(s) Single Employee,Employee and Family Retiree. Not Covered Specifi Benefit Premium Rate $12.63 per Single Employee per month $32.56 per Employee and Family per month Premiu Due Date The Policy Renewal Effective Date and the first day of e.ch succeeding month. h � 02�I SL Schedule of Benefits Aggregate Benefit Origin.l Aggregate Benefit Effective Date January 1,2005 Benefit i S s ecifications Renew.1 Policy Year January 1,2006 through December 31,2006 Reimb rsement Percentage 100%of Eligible Expenses Covere. Benefits Medical Prescription Drug Plan(PDP) Aggregate Benefit Maximum $1,000,000 Aggregate Benefit Maximum Eligible Expens-s Per Covered Person $150,000 Aggre Late Deductible Factor("ADF") The ADF per Benefit Month for each Covered Unit by C c vered Benefit is as follows: Covered Benefit Covered Unit F Medical Single Employee, $1,1 2.40 Employee and Family PDP Single Employee, $34:.25 Employee and Family Minim m Aggregate Deductible The Minimum Aggregate Deductible for the current Poli y Year is the greater of: a) $10,316,863;or b) 90%of the Monthly Aggregate Deductible for the fir t month of the Policy Year,then multiplied by 12. Aggre=.ate Benefit Attachment Point The Aggregate Benefit Attachment Point is the greater o II: a) the sum of the Monthly Aggregate Deductibles for thb Policy Year; or b) the Minimum Aggregate Deductible. Aggregate Benefit Claims Basis Paid Eligible Expenses include only those expenses Paid du ' g the Policy Year. Covered Unit(s) Single Employee,Employee and Family Retires Not Covered Aggregate Benefit Premium Rate $1.00 per Renewal Policy Year. Premi m Due Date The Policy Renewal Effective Date and the first day of e.ch succeeding Policy Year. 02-SL iv I� , Section I Definitions I Alter ative Care:For the purpose of determining Eligible Expenses under this Policy,Alternative Care eans a plan o Treatment,identified through case management services provided to Your Plan,which may not b; cover-• under Your Plan,but which We may consider for reimbursement because the Treatment is cost-e fective and M-dically Appropriate and Necessary for the care of a Covered Person.Alternative Care must satisfy the requir:ments set forth in Section II,Expenses Eligible for Reimbursement. Bene t Month:Any calendar month during which this Policy is in force. Catas irophic Diagnosis:Any medical condition which is a special risk on Our Special Risk Questionriai e. Claim. Basis:The period of time,shown on the Schedule(s)of Benefits,during which Eligible Expenses must be Incurr:d by a Covered Person and Paid by You to be eligible for reimbursement under this Policy. Cover•d Benefits: The benefit provisions of Your Plan that are insured for stop-loss coverage under this 'olicy. The C o vered Benefits for this Policy are shown on the Schedule(s)of Benefits. Cover•d Person:A person enrolled in Your Plan and entitled to receive benefits under Your Plan while t is Policy is in force.Retirees,as defined by Your Plan,may be Covered Persons if they are included on the Sched le(s)of Benefits. Cover•d Unit:A category of participants under Your Plan.The Covered Unit(s)for this Policy are show on the Sched le(s)of Benefits. Depen a ent:A person enrolled in Your Plan and entitled to receive benefits under Your Plan as a depende t of a Cover:d Person. Drug r Alcohol Dependence:Dependence on,or abuse of,a chemical substance or alcohol as classified by the curren' edition of the Diagnostic and Statistical Manual of the American Psychiatric Association("DSM" or a comp. able manual if the American Psychiatric Association stops publishing the DSM. Exper mental or Investigational Treatment:For the purpose of determining Eligible Expenses under th s Policy, a Treatment(other than covered Off-Label Drug Use)will be considered by Us to be experimental or investi:ational if: 1. The Treatment is governed by the United States Food and Drug Administration("FDA")and the DA has not approved the Treatment for the particular condition at the time the Treatment is provided; r 2. The Treatment is the subject of ongoing Phase I,II,or III clinical trials as defined by the National Institute of Health,National Cancer Institute or the FDA;or 3. There is documentation in published U.S.peer-reviewed medical literature that states that further research,studies,or clinical trials are necessary to determine the safety,toxicity or efficacy of the Treatment. Incurr•d: The date on which Treatment is provided. Indep Indent Review Panel:A panel retained through a third party vendor of medical review services that is compri.ed of three physicians who are board-certified in the medical specialty or subspecialty that most tyl ically admini.ters the Treatment under review. Medic•1 Management Vendor:A third party hired to reduce or control the cost of services or supplies pr vided to Cove red Persons under Your Plan. 02;SL 1 Section I Definitions Medic Hy Necessary and Appropriate:For the purpose of determining Eligible Expenses under this Po icy,a medic lly necessary and appropriate Treatment is one that We determine meets all of the following criteri : 1. It is recommended and provided by a licensed physician,dentist or other medical practitioner wh is practicing within the scope of his or her license;and 2. It is generally accepted as the standard of medical practice and care for the diagnosis and treatme t of the particular condition;and 3. It is approved by the FDA,if applicable. Ment.1 Illness:For the purpose of determining Eligible Expenses under this Policy,Mental Illness includes,but is not 'united to,bipolar affective disorder,schizophrenia,psychotic illness,manic depressive illness,depression and depressive disorders,anxiety and anxiety disorders and any other mental and nervous condition classi ied in the D I .Mental Illness does not include any condition listed in Appendix G of the DSM-IV,titled"ICD 9-CM Codes for Selected General Medical Conditions and Medication Induced Disorders,"or any comparable li ting if Appen•ix G is no longer published. Off-L.bel Drug Use:The use of a drug for a purpose other than that for which it was approved by the F9A. Origi al Aggregate Benefit Effective Date: When We provide You with Aggregate Benefit coverageiu der this Policy for consecutive Policy Years,the Original Aggregate Benefit Effective Date is the date Aggregate enefit couera:e first became effective in the consecutive year period. Origi al Specific Benefit Effective Date: When We provide You with Specific Benefit coverage under t is Policy for consecutive Policy Years,the Original Specific Benefit Effective Date is the date Specific Ben fit covera:e first became effective in the consecutive year period. Paid: he date Your check or draft for payment of expenses Incurred by a Covered Person is issued and d livered to the payee,provided that the account upon which the payment is drawn contains sufficient funds to permit the check 'r draft to be honored. Plan: our self-funded employee benefit plan established to provide benefits to Covered Persons as described in Your •Ian document.For the purpose of determining benefits payable under this Policy,the Plan shall not include any . endments made to the plan document after the Original Aggregate Benefit Effective Date or the!Original Specifc Benefit Effective Date,whichever is earlier,unless We notify You in writing from Our U.S. Headq'arters that We accept the amendment. Policy older:You,the legal entity to whom this Policy is issued. Prescr ption Drugs: For the purpose of determining Eligible Expenses under this Policy,Prescription Drugs includes all prescription drugs covered under Your Plan,other than prescription drugs administered to a Covered Person while he or she is confined in a hospital or other medical facility. Prescr ption Drug Plan:A benefit provision of Your Plan,or a separate employee benefit plan maintain d by You,u der which prescription drug expenses are paid independently of other medical expenses.Expenses incurre• under a Prescription Drug Plan will be included as Eligible Expenses only if the Prescription Drug Plan is incl ded as a Covered Benefit in the Schedule of Benefits.A Prescription Drug Plan does not mean prescription drug e penses paid subject to any deductibles and coinsurance applicable to other medical benefits under Your Plan. Provid•r Network:A Preferred Provider Organization(PPO),Exclusive Provider Organization(EPO),P?int of Servic; Plan(POS),self-funded Health Maintenance Organization(HMO),or any managed care network offered under our Plan. 02-SL 2 • III i Section I Definitions 1 Reim ursement Percentage: The percent of Eligible Expenses that will be considered for reimbursement under this P.licy. Sched le of Benefits:This Policy's schedule of Specific Benefit coverage or Aggregate Benefit coverag provid-d under this Policy. it Speci•I Risk Questionnaire:A report used to provide Us with certain information We require to underwrite this Policy Third Party Administrator("TPA"):A third party that You have entered into an agreement with to provide admin strative services to Your Plan.Your TPA is not Our agent. Trans I lant: The transplant of organs from human to human.For the purposes of determining Eligible Ex enses under this Policy,Transplant includes only the following transplants:heart,heart and lung,lung(single o double),liver,kidney,pancreas,kidney and pancreas,human bone marrow and stem cell transplantation d reinfu1ion.A Transplant must be performed at a Transplant Facility in order to be considered for reimbursement under 'his Policy. Skin and Cornea transplants are not considered a"Transplant"for the purpose of determining Eligibl Expenses under this Policy,but are considered Eligible Expenses if covered by your Plan. Trans s lant Facility:A hospital or facility which is accredited by the Joint Commission on Accreditation f Health are Organizations to perform a Transplant and: Fo organ transplants: is an approved member of the United Network for Organ Sharing for such Tran plant or s approved by Medicare as a transplant facility for such Transplant. Fo unrelated allogeneic bone marrow or stem cell transplants:is a participant in the National Marrow Donor Pro gram. • Fo autologous stem cell transplants: is approved to perform such Transplant by: (a)the state where th Tr.nsplant is to be performed; or(b)Medicare;or(c)the Foundation for the Accreditation of Hemopoietic Ce 1 Therapy.Outpatient facilities must be similarly approved. Treat ent: Any treatment,procedure,service,device,supply or drug provided to a Covered Person. Usual ;nd Customary Fee:For the purpose of determining Eligible Expenses under this Policy,"Usual"means the fee usually charged for a particular service by a provider;"Customary"means a fee in the range of usu 1 fees charge d by similar providers in the same geographic area. U.S.H•adquarters:Our United States headquarters located at One Sun Life Executive Park,Wellesley Hills, M .ssa.husetts. 02-SL 3 Section II Benefit Provisions Specific Benefit Defini ions S ecific Benefit Deductible:The amount of Eligible Expenses relating to a Covered Person that You must pa before You become eligible for a Specific Benefit.The Specific Benefit Deductible is shown on tie Sc edule of Benefits.In no event will the Specific Benefit Deductible be less than 5%of expected claims or $1 0,000,whichever is less. Specific Benefit Lifetime Maximum Reimbursement:The maximum amount We will ever reimburse with respect to any Covered Person.The Specific Benefit Lifetime Maximum Reimbursement is shown on the Sc edule of Benefits. Speci c Benefit The Specific Benefit for any Covered Person for any Policy Year equals: 1. the total amount of Eligible Expenses for the Covered person;minus 2. the Specific Deductible; m ltiplied by the Reimbursement Percentage shown on the"Schedule of Benefits-Specific Benefit,"if that Re mbursement Percentage is less than 100%. The S.ecific Benefit payable with respect to any Covered Person is subject to the Specific Benefit Lifetime Maxi um Reimbursement. 02-'SL 4 Section II Benefit Provisions Aggregate Benefit Defini ions A gregate Benefit Attachment Point: The amount of Eligible Expenses You must pay during the A.gregate B-i efit Claims Basis before We will consider an Aggregate Benefit claim.The Aggregate Benefit Att.chment Point is shown on the Schedule of Benefits.In no event will the Aggregate Benefit Attachment Point e less th. 120%of expected claims. Aggregate Deductible Factor:The deductible factor per Benefit Month per Covered Unit by Covere Be efit.The Aggregate Deductible Factor for each Covered Benefit is shown on the Schedule of Ben fits. Aggregate Benefit Maximum Eligible Expenses per Covered Person:The maximum amount of1El gible Expenses for any one Covered Person that will be used to calculate the Aggregate Benefit.The Aggregate Be efit Maximum Eligible Expenses per Covered Person is shown on the Schedule of Benefits. M nimum Aggregate Deductible:The minimum amount of Eligible Expenses You must pay before ou bet ome eligible for an Aggregate Benefit.The Minimum Aggregate Deductible is shown on the Sche•ule of Be efits. Mt nthly Aggregate Deductible:The sum of the deductibles for all Covered Benefits for each Benefi Month.The deductible for each Covered Benefit is calculated by multiplying the number of Covered nits on th- first day of the Benefit Month by the Aggregate Deductible Factor for each Covered Benefit.The cal ulation of the Monthly Aggregate Deductible is subject to the 5%Adjustment Rule. 5° Adjustment Rule:If the Monthly Aggregate Deductible decreases from one month("Month A")to the ne t("Month B"),for any reason,the Monthly Aggregate Deductible for Month B shall not be less;th. 95% of he Monthly Aggregate Deductible for Month A. Aggre ate Benefit The Aggregate Benefit equals: 1. the total amount of Eligible Expenses for all Covered Persons,subject to the Aggregate Benefit;M. imum Eligible Expenses Per Covered Person;minus the greater of 2. the Aggregate Benefit Attachment Point or the Minimum Aggregate Deductible; mu tiplied by the Reimbursement Percentage shown on the"Schedule of Benefits—Aggregate Benefit"if tha Reimbursement Percentage is less than 100%. The AtA:regate Benefit will be calculated after the end of the Aggregate Benefit Claims Basis. Aggregate Benefit Maximum The Aa: egate Benefit We will pay will not exceed the Aggregate Benefit Maximum shown on the Sched le of Benefit.. 02-SL 5 Section II Benefit Provisions Expenses Eligible for Reimbursement Eligib e Expenses Eligib le Expenses include any amount paid by You for Medically Necessary and Appropriate expensesi incurred by a Clivered Person which: ' 1. Have been paid in accordance with the terms of Your Plan; and 2. Were Incurred and Paid during the applicable claims basis;and 3. Are paid under a Covered Benefit shown on the Schedule of Benefits;and 4. Are not otherwise excluded under this Policy. Alter ative Care In add tion to satisfying Eligible Expenses criteria 2,3 and 4 above,expenses related to Alternative Care may be considered Eligible Expenses when all of the following additional criteria have been satisfied: 1. You demonstrate to Our satisfaction that providing the Alternative Care resulted in a cost savings to e Plan; and 2. The Alternative Care was recommended by case management services provided to Your Plan;an 3. The Alternative Care was Medically Necessary and Appropriate;and 4. The Alternative Care was provided with the consent of the Covered Person,or his/her representat ve,and with the approval of the Covered Person's licensed health care provider,and was approved by Yo a or Your TPA;and 5. The Alternative Care replaces Treatment that would be covered under Your Plan;and 6. The Alternative Care expenses do not exceed the maximum allowed under Your Plan for the Treatment replaced by the Alternative Care; and 7. If the Alternative Care is provided in lieu of inpatient hospitalization,the Covered Person meet utilization review criteria acceptable to Us for inpatient hospitalization for the entire period the! Alternative Care is provided.In no event will such Alternative Care that exceeds 90 days be consi.ered Eligible Expenses unless approved by Us. Off-L.bel Drug Use In Ladd' ion to satisfying the criteria for Eligible Expenses set forth above,expenses related to Off-Label D g Use may b: considered Eligible Expenses when all of the following additional criteria have been satisfied: 1. The drug is not excluded under Your Plan; and 2. The drug has been approved by the FDA; and 3. You can demonstrate to Our satisfaction that the Off-Label Drug Use is appropriate and generally accepted for the condition being treated; and rr 4. If the drug is used for the treatment of cancer,the American Medical Association Drug Evaluapo s,The American Hospital Formulary Service Drug Information,or The Compendia-Based Drug Bulletin recognize it as an appropriate treatment for that form of cancer. Reim i ursement of Certain Fees Eligibl- Expenses will also include the following fees Incurred and Paid by You,when approved by Us t at Our U.S.H-adquarters: 1. Reasonable hourly fees for case management services provided by a registered nurse case manager retained by You or Your TPA;and 2. Fees for: (a)hospital bill audits;(b)access to non-directed provider networks;and(c)negotiating out of network bills. Such f:es shall be considered Eligible Expenses only if You can demonstrate to Us that the work which g nerated the fee resulted in a cost savings to the Plan.If the Plan can demonstrate such a cost savings,We will reimburse You u s to 25%of the amount saved. Fees c arged by Your TPA or any subsidiary of Your TPA for any of these services will be considered Eli ible Expenses only if prior approval has been obtained in writing from Us at Our U.S.Headquarters. 02;SL 6 ,Ir � Section II Benefit Provisions Expenses Eligible for Reimbursement State 11 ealth Care Surcharges If You pay a state health care surcharge imposed by Louisiana,Massachusetts or New York in connection with the pa ment of Eligible Expenses,such health care surcharges are included as Eligible Expenses. We will only reimb rse health care surcharges imposed by New York if You are registered with the New York Depart ent of Health 02-SL 7 ( Section II Benefit Provisions Limitations and Exclusions Nye WI 1 NOT reimburse You for: 1.i'; E Tenses for medical services rendered to a Covered Person by the Covered Person's family member or rel.tive. 2.' E senses relating to an injury or illness arising out of,or occurring during the course of,a Covered P rson pe forming any occupation for wage or profit. 3. E enses for any cosmetic Treatment as defined in Your Plan.This exclusion does not apply to expe es relating to breast reconstruction after mastectomy. 4. E y.enses for any Experimental or Investigational Treatment,or for any hospital confinement or Treatment th.t results from Experimental or Investigational Treatment. 5. E 'senses for any transplant not included in the definition of Transplant. 6.'1 E 'senses relating to non-human organ or tissue transplants,gene therapies,xenographs or cloning. 7.; E 'senses for any Treatment administered outside the United States if the Covered Person traveled to the location where the Treatment was received for the purpose of obtaining the Treatment. 8. Ex,.enses for benefits in excess of Your Plan's limits,or expenses that are excluded under Your Plan. 9. Ex.enses in excess of the Usual and Customary Fee. 10. y amount paid by You in excess of a negotiated provider discount,or any penalty or late charge incurred, or:ny discount lost,unless previously approved in writing by Us at Our U.S.Headquarters. f 4 11 Ex.enses associated with the administration of Your Plan including,but not limited to,claim paymen fees, co.t containment administrative fees,PDP administration fees,PPO access fees,premium functions, edical re iew and consultant fees,unless otherwise covered under this Policy. 12. Ex senses paid by You relating to any litigation concerning Your Plan,including,but not limited to;a orneys' fe=s,extra-contractual damages,compensatory damages and punitive damages. 13. A portion of an expense which You are not obligated to pay under Your Plan,or which is reimburs.ble to Y. under: a) another group health benefit program; or b) a government or privately supported medical research program;or c) Medicare;or d) any coordination of benefits or non-duplication of benefits provision of Your Plan;or - e) worker's compensation;or f) any other source. 14. Ex.enses for claims submitted to Us that are not submitted in accordance with the Proof of Claim pro isions of his Policy. 15 Ex senses incurred by a person who is employed by You at any unit,subsidiary or division of Yours t t has 1. no'been underwritten by Us. 16.E Ex senses incurred for any illness or injury due to,or aggravated by,war or an act of war,whether dec ared or undeclared. 02-SL 8 Section II Benefit Provisions Limitations and Exclusions 17. If our Plan does not exclude coverage for conditions for which a Covered Person received Treatment within 6 onths prior to enrolling in Your Plan,expenses for any such condition will be excluded from rep bursement under this Policy for a period of twelve(12)months from the Covered Person's effective date un.er Your Plan(the"12 month period").The 12 month period will be reduced on a month for month basis by any"creditable coverage"(as defined in the Health Insurance Portability and Accountability Act of 1996, as . ended)attributable to the Covered Person. 18. E .ens es paid by You for any Treatment authorized or approved under any provision of Your Plan which: a) allows the plan administrator to approve alternative care or alternative treatment;or b) allows the plan administrator to alter,modify,or waive Plan provisions or limitations;or c) grants You or Your plan administrator discretion to approve coverage for Treatment not otherwise covered under Your Plan; un ess the Treatment satisfies the criteria for Alternative Care set forth in Section II. 19. E 'senses covered under a Prescription Drug Plan,unless Prescription Drug Plan coverage is a Cover d Be efit on the Schedule of Benefits. 20. Exl.enses for Treatment of Mental Illness and Drug or Alcohol Dependence will be limited to the less-r of I, Y.ur Plan's maximum benefit for any such condition or the Specific Benefit Deductible. .11 i I I� I 02SL 9 � i '!' Section III i Claim Provisions Proof i f Claim Proof of claim must be provided to Us at Our U.S.Headquarters. Sp'eci c Benefit W,itten proof of claim,in a form and content satisfactory to Us,must be provided to Us as soon as re onably po,sible after the Specific Benefit Deductible for a Covered Person has been satisfied.Proof of claim rust be provided to Us no later than 12 months after the end of the Specific Benefit Claims Basis during w14ic the cl.i m arose. Pro of of claim for a Specific Benefit claim shall include the following: 1. a fully completed claim form; 1i 2. a copy of the Covered Person's original enrollment record and records of any change in the Covered Person's coverage under Your Plan; 3. copies of all bills and invoices for expenses submitted for reimbursement under this Policy; 4. proof of payment of any expenses submitted to Us for reimbursement under this Policy;and 5. any additional information We may require to fulfill Our obligations under this Policy. Aggregate Benefit W itten proof of claim,in a form and content satisfactory to Us,must be provided to Us as soon as re..onably po•sible after the end of the Aggregate Benefit Claims Basis for the Policy Year.Proof of claim must .e provided to Us no later than twelve(12)months after the end of the Aggregate Benefit Claims Basis. Pro of of claim for an Aggregate Benefit claim shall include the following: 1. a complete aggregate calculation report; 2. a detailed claims history report for all Eligible Expenses Incurred and Paid during the Aggreg to Benefit Claims Basis; 3. a report listing all Covered Units eligible for benefits under Your Plan at any time during the Aggregate Benefit Claims Basis; 4. a copy of Your Plan in effect during the Policy Year and any amendments thereto; 5. if Prescription Drug Plan coverage is included as a Covered Benefit on the Schedule of Benefits,a copy of all prescription drug invoices and an itemization thereof,including the amounts of an) rebates received by You;and 6. any additional information We may require to fulfill Our obligations under this Policy. I Appea of a Claim Determination You m„y appeal any claim determination made by Us under this Policy by submitting a written appeal to s at Our U. S.Headquarters within sixty(60)days from the date of Our detein ination.Your appeal should stat the basis o Your disagreement with Our determination and should include all documentation and information suppo ling Your appeal that has not been previously provided to Us. W An'app al of any claim determination made by Us on the grounds that the Treatment provided was: (a)not edically Necessary and Appropriate;(b)cosmetic;or(c)Experimental or Investigational must in lude an Indepe dent Review Panel report which includes each panel member's report and the panel's consensus report. The In.ependent Review Panel report is to be provided at Your expense.The members of the Independent Re'vie Panel must be mutually acceptable to You and Us. 02-SL 10 ti I Section III Claim Provisions Defer ed Payments by You You m st obtain prior written approval from Us at Our U. S.Headquarters in order for any Eligible Expenses Incurri d in the Policy Year,but Paid after the end of the applicable claims basis to be considered eligible for reimb rsement under this Policy. Paym:nt of Claims All be efits due under this Policy will be paid to You.During the Policy Year,reimbursements will be disbursed when t e amount payable exceeds$500.00.Any reimbursable amount remaining unpaid at the end of a'P:1icy Year ill be paid after the end of the Policy Year. I ' I , 02-SL 11 ill • Section IV Your Rights and Responsibilities Autho izations to Release Information You ar- responsible for authorizing Your TPA,Plan Administrator,case manager or other third party service provide r to release to Us information We request to underwrite,review potential claims,make claim determl nations,calculate potential reimbursements,or perform other obligations under this Policy.If We do not receiv:requested information,it may result in the delay,reduction or denial of a claim. Disclo•ure Requirements This P o licy has been underwritten based upon the information You provided to Us concerning all persons ligible for be -fits under Your Plan on the Original Specific Benefit Effective Date and/or the Original Aggregate Benefi i Effective Date(or on the effective date of any class of Covered Persons added thereafter).This lintludes, but is of limited to,those persons who are a special risk as defined in the Special Risk Questionnaire. Your s gnature on the Application for this policy warrants and represents to Us that: 1. You or Your authorized representative have consulted with Your precertification,utilization revie and Medical Management Vendors and Your TPA,or former TPA,to determine who must be disclosed as a special risk on the Special Risk Questionnaire;and 2. You have identified any person who is or maybe a special risk by either listing them on the Specia Risk Questionnaire or by indicating any such person on the reports listed on the Special Risk Questionnaire. If You ail to disclose an individual as a special risk,who should have been disclosed as a special risk in accord. ce with the Special Risk Questionnaire,We will have the right to revise the premium rates,deduc ibles, deducti'le factors and terms and conditions of this Policy in accordance with Our underwriting practices i effect at the f e the Policy was underwritten,retroactive to the Original Specific Benefit Effective Date and/or t e Original Aggregate Benefit Effective Date. i I I' I � I i I 02-SL 12 P' � Section IV Your Rights and Responsibilities Repor ing Requirements You . e required to provide periodic reports to Us as described below.If You,or Your TPA,do not provi e the report', or do not provide them on a timely basis,We reserve the right,once We receive them,to take wh.tever action e could have taken if the reports had been provided when required. Such action may include,but;s not limite• to,the right to revise premium rates,deductibles,and deductible factors,and to do so retroactive t• the Origin:1 Specific Benefit Effective Date and/or the Original Aggregate Benefit Effective Date. Speci c Benefit Reporting Y•u,or Your TPA,are required to provide Us with notice of any potential Specific Benefit claim wit in thi -one(31)days of the date: 1. a Covered Person's Eligible Expenses exceed 50%of the Specific Benefit Deductible;or 2. You,Your TPA,or Your medical management,utilization review or precertification vendors,or any other party acting on Your behalf,are notified that a Covered Person has been diagnosed with or treated for,a Catastrophic Diagnosis. Aggregate Benefit Reporting Y•u,or Your TPA, are required to provide Us with a monthly report that lists: 1. the total amount of Eligible Expenses Incurred by any Covered Person and Paid by You,or P id on Your behalf,during the Benefit Month;and f 2. the number of each type of Covered Unit on the first day of the Benefit Month. Y• must provide the Aggregate Benefit report to Us within thirty-one(31)days after the end of each enefit M•nth. Renew:1 Reporting If ' ou intend to renew this Policy,then three months prior to the end of the Policy Year,You,or You TPA, ar:required to provide Us with a report which includes the following information: 1. monthly Paid claims and enrollment data,organized by Covered Benefit; 2. large claim information,including amount,diagnosis and prognosis,and any Covered Person ho has been diagnosed with a Catastrophic Diagnosis; 3. a census of all Covered Persons; 4. a summary of the number of Covered Persons by workplace zip code,if this Policy covers Em loyees at multiple locations; 5. a summary report of precertification,utilization review and case management services; I 6. a summary report of Your Provider Network(s)or per diem arrangements,setting forth the av rage hospital discount or per diem charge per day;and 7. a copy of changes adopted by or proposed for Your Plan. Plan CI anges You m st notify Us in writing at Our U. S.Headquarters at least thirty-one(31)days before the effective date of any, ch. ge in,or to: 1. Your Plan; 2. Your TPA; 3. Your Provider Networks; or 4. Your Medical Management Vendors. Our pH•r written agreement is required before the coverage under this Policy will apply to any such change. Othe se,benefits under this Policy will be paid based upon the terms of Your Plan as it existed prior to ! y such c . ge.We reserve the right to terminate this Policy as of the effective date of any change in or to IY ur Plan,Y•ur TPA,Your Provider Network,or Your Medical Management Vendor. 02-SL 13 • Section IV Your Rights and Responsibilities Notice of Legal Action You a:ree to give Us prompt notice of:(a)any event that might result in a lawsuit relating to this Policy; or(b) any la suit involving this Policy;and to promptly provide Us with copies of any correspondence and ple dings relatin;;to any such event or lawsuit. Hold armless You a_ree to defend,indemnify and hold Us harmless from and against any and all claims,demands and auses of action .f every kind,relating to any litigation,that We,without Our fault,become involved with that relates to this Po icy or Your Plan.You shall pay any and all attorneys' fees,costs,expenses,and damages(including compe satory,exemplary or punitive damages)incurred by Us,or payable by Us,in connection with any uch litigation.This Hold Harmless provision shall not apply to litigation solely between You and Us relating t this Policy. Refun o of Overpayment If We, ou,or Your TPA determine that We have overpaid You under this Policy,You will promptly re nd such overpa ment to Us within 60 days of such a determination.If We are required to take legal action to collet such overpa ment,You agree to indenmify Us for any costs of collection,including,but not limited to,attorne s fees and co I costs. Respo sibility For Your TPA You ar• solely responsible for the actions of Your Plan Administrator,Your TPA and any other agent of Yours. Your TI'A acts on Your behalf,not on Our behalf.Your TPA is not Our agent. We are not responsible for y compe sation owed to,or claimed by,Your TPA or other agents for services provided to,or on behalf of, our Plan.T is Policy does not make Us a party to any agreement between You and Your TPA,nor does it m e Your TPA a 'arty to this Policy. Right i f Recovery You m'st pursue all valid claims including,but not necessarily limited to,claims for restitution, constructs e trust,equitable lien,breach of contract, injunction,and any other state or federal law claims You or Your Plan may ha e against any third party responsible,in whole or in part,for any Eligible Expenses Paid by You.You must i mediately advise Us of any amount You recover from them. We reserve the right to pursue any Iano all • such cl.ims not pursued by You,and You agree to assign such claims to Us upon Our request. • 02-SL 14 I Section V Our Rights and Responsibilities Audit We ha e the right to inspect and audit any and all of Your records and procedures,and those of Your TP and any of er party,that relate to any claim made by You under this Policy.We have the right to require docum-ntation from You that demonstrates You paid an Eligible Expense and that the payment was made in accord:nce with the terms of Your Plan. We reserve the right to employ a third party,at Our expense,to a sist Us with . y audit function. Deter ination of Eligible Expenses For th,purpose of determining Eligible Expenses under this Policy,We have the right to determine wheth r an expens• was Paid by You in accordance with the terms of Your Plan. Cost lintainment ' We ha the right to retain the services of a Medical Management Vendor,at Our expense,to assist Us wi h cost contaient when We anticipate that a Covered Person's Eligible Expenses will exceed 50%of the Specific BenefDeductible during the Policy Year. Co'nfintiality We wiltprotect the privacy and confidentiality of all personally identifiable and/or medical information'pr vided to Us the course of underwriting or administering this Policy in accordance with Our policies and applic ble state . federal laws. Recou o ment We ha e the right to recoup from any benefit payable to You under this Policy any premium You owe to s that has not been paid.Our right of recoupment does not impair Our right to terminate this Policy for non-payment of premiu 0 under the Termination Provisions of this Policy. di Right t i Recalculate We hay- the right to recalculate any Specific Benefit Premium Rate, Specific Benefit Deductible,Aggregating Specifi 4 Deductible,Aggregate Benefit Premium Rate,Aggregate Deductible Factor or Minimum Aggreg to Deduct'.le with respect to this Policy Year whenever any one or more of the following events occur: ' 1. Your Plan changes; 2. You change Your TPA,Your Provider Network(s),or Medical Management Vendor(s); ii 3. this Policy is amended; ` ! 4. the number of Covered Units on the first day of a Benefit Month increases or decreases by more th 15% from the number of Covered Units on the first day of the Policy Year; 5. he number of Covered Units on the first day of a Benefit Month increases or decreases by more th n 10% from the first day of the prior Benefit Month; ,6. . unit,division,subsidiary,or affiliated company of Yours is added to,or deleted from,this Policy; 7. he amount of Eligible Expenses paid in any one of the three(3)months immediately preceding th I Policy I ffective Date(the"three month period")exceeds 125%of the monthly average of Eligible Expen es I ncurred during the nine(9)months immediately preceding the three month period;or 8. here are changes in Your,or Your TPA's,claim paying system or payment practices that causes a ariation of fifteen(15)days or more in the most recent twelve(12)month average of claim proses ing ime. Any rig t to recalculate exercised under this section may be made retroactive to the Policy Effective Date a Our election.Any recalculation will be made in accordance with Our underwriting practices in effect at the timed the Policy as underwritten.The right to recalculate shall survive the termination of this Policy. 02-SL 15 I Section V Our Rights and Responsibilities Right i f Reimbursement Any pi rtion of an Eligible Expense which You recover from a third party: 1. is not eligible for reimbursement under this Policy;and 2. cannot be used to satisfy any deductible or attachment point under this Policy;and 3. must be repaid to Us if We previously reimbursed You for it. Any repayment amount You owe Us may be reduced,with Our consent,by any reasonable and necessary expens-s You incurred in obtaining the recovery from the third party.Any repayment amount You owe to Us shall s rvive the termination of this Policy. I I P I i I I _ 02-SL 16 • Section VI General Provisions Assig ment Your i terest in this Policy cannot be assigned. Bankr ptcy or Insolvency The b. ptcy,insolvency,dissolution,receivership or liquidation of You,Your Plan or Your TPA will o of impos=upon Us any obligations other than those set forth in this Policy. Cleric•1 Error In.the :vent of a clerical error in this Policy,the Policy will be revised to correct the error.Your failure to: 1. report the existence of a Covered Person;or 2. file proof of claim in a timely manner;or 3. comply with the reporting requirements of this Policy; shall ni t constitute clerical error. Entire ontract This Policy,along with any Attachments,Riders,Endorsements or Amendments,and the Application and pecial Risk Q I estionnaire completed by You constitutes the entire contract of insurance between Us. Legal •ction You m.y not bring a legal action against Us to recover on this Policy earlier than sixty(60)days after You have furnish.d Us with proof of claim in accordance with the Proof of Claim provisions of this Policy.You ma not bring . y legal action against Us to recover on this Policy after two(2)years from the time proof of claim s require. under this Policy. Misrep.esentation If 1. ou make any misstatement,omission or misrepresentation,whether intentional or unintentional,i the i nformation or documentation You,Your TPA or any other party acting on Your behalf,provide to Us, • d which We rely upon during the underwriting of this Policy;or 12. .fter this Policy is issued,We learn of expenses or claims that were incurred or paid,but not rep ort-d to s,during the underwriting of this Policy; We,'hav: the right,at Our election,to rescind this Policy or to revise the premium rates,deductibles,and terms and con•itions of this Policy in accordance with Our underwriting practices in effect at the time the Policy was underwr tten.Any such revisions may be made retroactive to the Policy Effective Date. No ERI'.A Liability Under no circumstance will We accept responsibility as a"Plan Administrator"or be deemed a"plan fiduci " with res ect to Your Plan under the Employee Retirement Income Security Act of 1974,as amended. Non-Pal ticipating Policy ThisiPol cy is non-participating and does not share in Our surplus earnings. Policy endment No Chan:.e in this Policy,or waiver of any of its provisions,will be valid unless such change or waiver is in writing a d agreed to by Us at Our U. S.Headquarters and made a part of this Policy.No agent,broker,TP ,or managin;:general underwriter has authority to change this Policy or waive any of its provisions. Policy R•newal This IPoli y may be renewed on the Policy Anniversary Date unless it has been terminated or is subject to to ination in accord.nce with the Termination Provisions of this Policy.Policy changes for any renewal policy willapiear on a revised S hedule of Benefits and/or a Policy amendment. Your payment of the renewal premium after receik of the revised S hedule of Benefits and/or Policy amendment constitutes acceptance of the renewal policy by You. 02-S4 17 Section VI General Provisions Premi m Provisions Premi m Payments Pr,mium is due on or before the Premium Due Date. Grace 'eriod A :race period of thirty-one(31)days will be allowed for the payment of each premium due after the irst premium has been paid.This Policy will continue in force during the grace period.If a premium is not paid by thi end of the Grace Period,this Policy will terminate,without notice to You,as of the last date for iw ich premium was paid. Premi m Data Y. must provide a report to Us with each premium payment,in a form satisfactory to Us,that lists: 1. the number of each type of Covered Unit,for each Covered Benefit,under Your Plan on the fi st day of the Benefit Month;and 2. the amount of premium paid. W: use such premium data reports solely to process premium.They do not replace any report requirel or wh ch may be required,under Section IV of this Policy. Severa s ility In;the :vent that any provision of this Policy is invalidated by a court of competent jurisdiction,all remain' g provisi ins of the Policy shall continue in full force and effect. Termi ation Provisions 1. If You fail to pay the premium,this Policy will terminate in accordance with the Premium Provisi n of this Policy. 2. If Your Plan is terminated,this Policy will terminate on the date the Plan terminated. 1.3. If You fail to maintain a minimum of 150 participants in Your Plan at any time during the Policy ear, We may elect to terminate this Policy at the end of the first month during which there are less than 150 participants. 4. This Policy will terminate at the end of the Policy Year unless renewed. 5. If You, or Your TPA,fail to satisfy any of Your obligations under this Policy,We may terminate t is Policy by giving You sixty(60)days advance written notice. 6. We may terminate this Policy within thirty-one(31)days of the end of the Policy Year. 7. You may terminate this Policy at any time by providing Us with 90 days advance written noticelat Our U. S.Headquarters. The pa ies to this Policy may agree in writing to terminate it at any time. Reinst•tement If this Policy is terminated for non-payment of premium,We may,at Our sole discretion,agree to reinstate it as of the"date it terminated upon payment of all outstanding premium. We may require You to provide certain' informa ion to Us before We will consider reinstating the Policy. Time L mitations If any ti e limitation in this Policy is less than that permitted by the law of the state in which the Application was taken,t e limitation is hereby extended to the minimum period permitted by the law. ' II 02-SL 18 Sun Life Assurance Company of Canada SunExcel® Transplant Benefit Rider Effecti e January 1,2005,this Rider is attached to and made part of Stop-Loss Policy No.69026 issued by Sun Life A,surance Company of Canada(the"Policy"). Introd ction Th- SunExcel®Transplant Benefit provides a number of benefits,which include: providing Covered Persons with access to Centers of Excellence Transplant Facilities; • reducing the Specific Benefit Deductible for a Covered Person who uses a Centers of Excellence Transplant Facility for a Transplant; • payment of the transplant network access fee; • reimbursement for travel and lodging expenses incurred by a Covered Person immediately prior o,and following,a Transplant if such expenses are covered under Your Plan;and • reimbursement for certain expenses and deductibles paid by the Policyholder. I Definit ons All capitalized terms used in this Rider shall have the meaning attributed to them by the Policy.For pu 'ose of this Rider,the following term shall be defined as follows: Centers of Excellence Transplant Facility:A Transplant Facility We have contracted with asp of the SunExcel®program. Requir•ments To qual fy for the SunExcel®Transplant Benefit,You and Your Plan must satisfy all of the following require ents: 41. Your Plan must: a) require precertification for Transplant related hospitalizations and outpatient Transplant proce es; o) offer a minimum Transplant benefit of$300,000.00; ) treat Centers of Excellence Transplant Facilities as in-network providers;and 12. ou must: .) amend Your Plan to include the SunExcel®Transplant Benefits listed in section 3 and 4 below .) require Your TPA and Provider Network(s)to permit Covered Persons to access SunExcel®Centers of Excellence Transplant Facilities; ) advise Your TPA and Medical Management Vendor(s)that Covered Persons may access Cente s of Excellence Transplant Facilities,and instruct Your TPA and Medical Management Vendor(s)to contact Us at 1-888-4ORGANS when they receive notice that a Covered Person may require a Transplant; ') advise Covered Persons that they may access Centers of Excellence Transplant Facilities if the need a Transplant;and ) agree to waive any exclusion under Your Plan that excludes expenses relating to the acquisition of an organ for a Transplant("organ acquisition expenses"),when organ acquisition expenses are inc uded in the global fee negotiated with a Centers of Excellence Transplant Facility. • 02-St-ST:R Sun Life Assurance Company of Canada p Y SunExcel® Transplant Benefit Rider Sv nE icel®Transplant Benefit If You satisfy the requirements set forth above,and a Covered Person has a Transplant performed at a Centers of Excell:nce Transplant Facility, We will: 1. reduce the Specific Benefit Deductible for the Covered Person by$10,000 for the Policy Year in which the Transplant occurs;and 2. pay any fee required for access to the Centers of Excellence Transplant Facility. In,addi ion,if Your Plan provides the following benefits as covered benefits under the SunExcel®Transpl. t Benefi ,Eligible Expenses will include: 3. up to$5,000.00 for any travel and lodging expenses incurred by the Covered Person and one companion immediately prior to,and following,the Transplant;and/or 4. up to$1,500.00 for any deductible and co-payments waived by,or paid to,the Covered Person'by Your Plan,for the year in which the Transplant occurs. diel President Secretary 1 02-SL- TBR it I Sun Life Assurance Company of Canada Endorsement This E dorsement is made part of the Policy to which it is attached. I. The Transplant Definition in Section I,"Defmitions,"is deleted and replaced by the following: Transplant:The transplant of organs from human to human,including bone marrow,stem cell . d cord blood transplants.Transplants include only those transplants that:(a)are approved for Medicare civerage on the date the Transplant is performed;and(b)are not otherwise excluded by this Policy. A Transplant must be performed at a Transplant Facility to be considered for reimbursement unde this Policy. Skin and cornea transplants are not considered a transplant for the purpose of determining I ligible Expenses under this Policy,but are considered Eligible Expenses if covered by Your Plan. II. Item 17 in Section II,"Benefit Provisions—Limitations and Exclusions,"is deleted. IL Effecti e Date:January 1,2005 President Secretary I I i I ' I � I III 02=SL- ND-1 Sun Life Assurance Company of Canada I I Endorsement This E o dorsement is made part of the Policy to which it is attached. Item 2 n Section II,"Benefit Provisions-Limitations and Exclusions,"is deleted and replaced by the following: 2. Expenses that are payable or reimbursable under any Workers' Compensation Law or similar legislation. Effecti e Date:January 1,2005 Ar, /Ye.. President Secretary II. I i II I I li I h I I �I • 02-SL-E D-2 IS . i I Sun Life Assurance Company of Canada Amendment No. 1 Tliis A endment is attached to and made part of Stop-Loss Policy No.69026 issued by Sun Life Assurance Comp. y of Canada(the"Policy"). Effecti e January 1,2005,retirees will not be included as Covered Persons under this Policy,except for those retiree as stated in Appendix A[Appendix A attached]. 14\ 11! '"."Aikt.41,,A,..0 President Secretary Il � ', 02SL-•MEND I Id j . lu �trrT Stop Loss Benefits Sun Life Assurance "` t SC-3221 Company of Canada IL -.• One Sun Life Executi e 'ark Li e Financial'' WellesleyHills,MA 024:1-5699 1 Dece ber 21,2005 City o Renton 1055 'outh Grady Way Rentoi,WA 98055 � I Attn: erri Shuhart RE:P.Hey Number: 69026 �II Dear r. Shuhart: Iri res•onse to your request,we have amended the above policy,effective January 1,2006. For y• r convenience,we have reissued the policy to include the requested changes in a single document.Please revie the enclosed policy,which replaces your present policy.This policy is reissued from the Policy Renewal Effect ve Date to reflect the changes indicated below. h � Amen.ment Effect ve Date Description of Change Jahn. 1,2006 Renewal Policy Year, Specific Benefit Deductible, Specific Benefit Claims Basis,Aggregate Internal Maximum, Medical Aggregate Deductible Factor and Minimum Aggregate Deductible 'h I Excep as stated in this Amendment,nothing contained herein shall be held to alter or affect any of the policy provis ons,including any prior amended policies,amendments,modifications,addendums, endorsements, attac ents or riders thereto. .11 We api.reciate this opportunity to assist you. Si' cer-ly, Stop- oss Benefits r I co,: Seattle Group Office stpc 10'19 2/03 Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies. www.sunlife-usa.com ,'`I, Sun `e; Life Fin ncial sM PRIVACY POLICY Intro•uction At tie Sun Life Financial group of companies,' protecting your privacy is i portant to us. Whether you are an existing customer or cons , dering a relationship with us, we recognize that you have an inte est in how we may collect, use and share information about yo . Sun ife Financial has a longtradition of safeguarding the rivacy of g g p its ustomers' information. We understand and appreciate the trust and confidence you place in us, and we take seriously our obligation 't main ain the confidentiality and security of your personal info' mation. We i vite you to review this Privacy Policy which outlines how we use and •rotect that information. Coll-ction of Nonpublic Personal Information by Sun Life Financial Collecting personal information from you is essential to our abili7.y tb offer you high-quality investment, retirement and insurance pro•ucts. When you apply for a product or service from us, we nee to obt.in information from you to determine whether we can provide it to you. As part of that process, we may collect information about yo , kno n as nonpublic personal information, from the following sources : • Information we receive from you on applications or other forms, such as your name, address, social security number and date of birth; • Information about your transactions with us, our affiliates or others, such as other life insurance policies or annuities it at you may own; and • Information we receive from a consumer reporting agency, uch as a credit report. Lim ted Use and Sharing of Nonpublic Personal Information by Sun Life Financial We se the nonpublic personal information we collect to help us provide the products and services you have requested and to mairt in and service your accounts. Once we obtain nonpublic personal inf•rmation from you, we do not disclose it to any third party except As :'ermitted or required by law. 'For a complete list of the Sun Life Financial member companies that have adopted this Privacy Policy,please see the riverse side of this Notice. 1 We m. y share your nonpublic personal information within Sun Life Financial to help us develop innovative financial products and , sery ces and to allow our member companies to inform you about the T11;ie ',tin Life Financial group of companies provides a wide variety,; f financial products and services including individual life insuranc , individual fixed and variable annuities and group life, disability, and edical stop-loss insurance. We a so may disclose your nonpublic personal information to companies that help in conducting our business or perform services on our behalf, or to other financial institutions with which we have join mark-ting agreements. Sun Life Financial is highly selective in choo.ing these companies, and we require them to comply with stric , stan.ards regarding the security and confidentiality of our customers' nonp blic personal information. These companies may use and disclose the information provided to them only for the purpose for which it is provided, as permitted by law. Ther- also may be times when Sun Life Financial is required to disclose its customers' nonpublic personal information, such as wh n comp ying with federal, state or local laws, when responding to a subp.ena, or when complying with an inquiry by a governmental agency o;r r-gulator. Our reatment of Information About Former Customers Our i.rotection of your nonpublic personal information extends beyond the i.eriod of your customer relationship with us. If your customer relationship with us ends, we will not disclose your information' tl nbn.ffiliated third parties other than as permitted or required by law. Sec rity of Your Nonpublic Personal Information We aintain physical, electronic and procedural safeguards that co ply wit federal and state regulations to safeguard your nonpublic p;er-onal information from unauthorized use or improper access. Emp oyee Access to Your Nonpublic Personal Information We restrict access to your nonpublic personal information to those emp oyees who have a business need to know that information in orier to .rovide products or services to you or to maintain your accoun s. Our employees are governed by a strict code of conduct and are 1 required to maintain the confidentiality of customer information. The following Sun Life Financial companies have adopted this Noti e. Qth:r Sun Life Financial affiliated companies have adopted their wn pri acy policies. Please check their websites for details. 1 Insu ance Companies Distributors/Broker-Dealers/Underwriters Sun life Assurance Company of Canada (U.S. Clarendon Insurance Agency, Inc. , I SLPC10523 03/03 q I opera'ions) Sun L'fe Assurance Company of Canada IFMG of Oklahoma, Inc. (U.S.) Sun L'fe Insurance and Annuity Company of IFS Agencies, Inc. I New Y.rk In'dep_ndence Life and Annuity Company IFS Agencies of Alabama, Inc. Keypo"t Life Insurance Company IFS Agencies of New Mexico, Inc. IFS Insurance Agencies of Ohio, Inc. IFS Insurance Agencies of Texas, Inc. Independent Financial Marketing Group, Inc. Keyport Financial Services Corp. IFMG Securities, Inc. LSC Insurance Agency of Arizona, Inc. LSC Insurance Agency of Nevada, Inc. LSC Insurance Agency of New Mexico, Inc. I I SLPC10523 03/03 Sun Life Assurance Company of Canada II STOP-LOSS POLICY Policy i older: City of Renton I Policy Number: 69026 y I P licy Effective Date: January 1,2005 Policy Renewal Effective Date: January 1,2007 This Policy is delivered in Washington and is subject to the laws of that jurisdiction. Sun Li e Assurance Company of Canada agrees to pay the benefits provided by this Policy in accordance ith the pr9visi.ns contained herein.This Policy is issued in consideration of the Application submitted by the Policy older,a copy of which is attached,and continued payment of premium by the Policyholder.The Application, Special Risk Questionnaire,and any Riders,Endorsements and Amendments to this Policy e made paft of his Policy. The Po icyholder will hereafter be referred to as"You,""Your,"and"Yours." Suln Li e Assurance Company of Canada will hereafter be referred to as"We,""Our"and"Us." When etermining any date under this Policy,all days begin at 12:00:00 a.m.and end at 11:59:59 p.m.st.o dard time fo Your headquarters. Sighed .t Our U.S.headquarters,One Sun Life Executive Park,Wellesley Hills,Massachusetts,by: .• President Secretary I I PLEASE READ YOUR POLICY CAREFULLY Non-Participating Thies is • reimbursement policy.You,or Your Plan administrator,are responsible for making benefit determi ations under Your Plan.We have no duty or authority to administer,settle,adjust or provide advice egarding claims filed under Your Plan. I Sun Sun Life A•surance Company of Canada is a member of the Sun Life Financial group of companies. 1 aeA ©2002 Sun ife Assurance Company of Canada,Wellesley Hills,MA 02481.All rights reserved. Life Financial I I I i I i 02-SL I � Table of Contents I, I Sectio.7 Description Page Schedule of Benefits iii II I I! Definitions 1 III Benefit Provisions 4 • Specific Benefit 4 • Aggregate Benefit 5 I • Eligible Expenses 6 • Limitations and Exclusions 8 III1 Claim Provisions 10 IVj Your Rights and Responsibilities 12 11 V Our Rights and Responsibilities 15 VII General Provisions 17 � I it • Premium Provisions 18 II, • Termination Provisions 18 11 11 I I II li I � 'I I II III 02-SL ii 11 11 I I Schedule of Benefits Specific Benefit Origi .1 Specific Benefit Effective Date January 1,2005 Bene t S ecifications Rene al Policy Year January 1,2007 through December 31,2007 Reimb rsement Percentage 100%of Eligible Expenses Colver-d Benefits Medical Prescription Drug Plan(PDP) Sp'ecifi,c Benefit Deductible $150,000 Specifi Benefit Lifetime Mai im Reimbursement $1,850,000 Specifi Benefit Claims Basis Paid II Eligible Expenses include only those expenses Incurred after January 1,2004 and Paid during the Policy Year. Covere. Unit(s) Single Employee,Employee and Family Retiree. Not Covered Specifi Benefit Premium Rate $15.84 per Single Employee per month II $40.85 per Employee and Family per month Prelmiu Due Date The Policy Renewal Effective Date and the first day of each succeeding month. ,III I I ,II li II I � II u I III I i I III 02-SL iii II I Schedule of Benefits Aggregate Benefit 1 � 6ligin 1 Aggregate Benefit Effective Date January 1,2005 Benefit Specifications R newal Policy Year January 1,2007 through December 31,2007 Reimbursement Percentage 100%of Eligible Expenses Cover d Benefits Medical Prescription Drug Plan(PDP) Aggre ate Benefit Maximum $1,000,000 Aglgreate Benefit Maximum Eligible Exppenses Per Covered Person $150,000 Aggregate Deductible Factor("ADF") The ADF per Benefit Month for each Covered Unit'lby Covered Benefit is as follows: 1 Covered Benefit Covered Unit ADF Medical Single Employee, $1,34 .52 Employee and Family i; PDP Single Employee, $368. 7 Employee and Family Minim m Aggregate Deductible The Minimum Aggregate Deductible for the current Poll Year 11 is the greater of: I I a) $12,277,221;or b) 90%of the Monthly Aggregate Deductible for the first ,1 month of the Policy Year,then multiplied by 12 11 Aggregate Benefit Attachment Point The Aggregate Benefit Attachment Point is the greater of: lil a) the sum of the Monthly Aggregate Deductibles for th Policy Year;or b) the Minimum Aggregate Deductible. 1 Aggregate Benefit Claims Basis Paid Eligible Expenses include only those expenses Paid durin the ,1 Policy Year. Coverea Unit(s) Single Employee,Employee and Family I Retirees Not Covered Aggreg.to Benefit Premium Rate $1.00 per Renewal Policy Year. 1 11 iu i Due Date The Policy Renewal Effective Date and the first day of each succeeding Policy Year. j 1 02-SL iv i I , it • it 'l Section I Definitions ; Alternative Care:For the purpose of determining Eligible Expenses under this Policy,Alternative Care means a plan of Treatment,identified through case management services provided to Your Plan,which may not b cover d under Your Plan,but which We may consider for reimbursement because the Treatment is cost-e fective and M dically Appropriate and Necessary for the care of a Covered Person.Alternative Care must satisfy the requir meats set forth in Section II,Expenses Eligible for Reimbursement. BIne t Month:Any calendar month during which this Policy is in force. Catas rophic Diagnosis:Any medical condition which is a special risk on Our Special Risk Questionnaire. Claim Basis:The period of time,shown on the Schedule(s)of Benefits,during which Eligible Expenses must be Inlii urr d by a Covered Person and Paid by You to be eligible for reimbursement under this Policy. Cover d Benefits:The benefit provisions of Your Plan that are insured for stop-loss coverage under',this Policy. The C vered Benefits for this Policy are shown on the Schedule(s)of Benefits. I Cover d Person: A person enrolled in Your Plan and entitled to receive benefits under Your Plan while this Policy s in force.Retirees, as defined by Your Plan,may be Covered Persons if they are included on the Sched le(s)of Benefits. Cover d Unit:A category of participants under Your Plan.The Covered Unit(s)for this Policy are shown on the Sched e(s)of Benefits. Depen ent:A person enrolled in Your Plan and entitled to receive benefits under Your Plan as a dependent of a Covere Person. Drug o Alcohol Dependence:Dependence on,or abuse of,a chemical substance or alcohol as classified 3y the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association("DSM")or a coinparle manual if the American Psychiatric Association stops publishing the DSM. II Experimental or Investigational Treatment:For the purpose of determining Eligible Expenses under thi Policy,. Treatment(other than covered Off-Label Drug Use)will be considered by Us to be experimental r inuesti.ational if: 1! 1. The Treatment is governed by the United States Food and Drug Administration("FDA")and the F�A has not approved the Treatment for the particular condition at the time the Treatment is provided; r 2. The Treatment is the subject of ongoing Phase I,II,or III clinical trials as defined by the National Institute of Health,National Cancer Institute or the FDA;or 3. There is documentation in published U.S.peer-reviewed medical literature that states that further i research,studies,or clinical trials are necessary to determine the safety,toxicity or efficacy of the Treatment. !I I Incurr•d: The date on which Treatment is provided. Indepe dent Review Panel:A panel retained through a third party vendor of medical review services that is compns-d of three physicians who are board-certified in the medical specialty or subspecialty that most typically adminis ers the Treatment under review. Medical Management Vendor: A third party hired to reduce or control the cost of services or supplies provided to Covered Persons under Your Plan. I• u i 02-SL 1 li i i I I � I Section I Definitions I Medically Necessary and Appropriate: For the purpose of determining Eligible Expenses under this Policy,a Medic lly necessary and appropriate Treatment is one that We determine meets all of the following criteria: ICI 1. It is recommended and provided by a licensed physician,dentist or other medical practitioner whb is practicing within the scope of his or her license;and 2. It is generally accepted as the standard of medical practice and care for the diagnosis and treatment of the particular condition;and ' 3. It is approved by the FDA,if applicable. I lent 1 Illness: For the purpose of determining Eligible Expenses under this Policy,Mental Illness includes,but isinot imited to,bipolar affective disorder,schizophrenia,psychotic illness,manic depressive illness,depression and de ressive disorders,anxiety and anxiety disorders and any other mental and nervous condition classified in the DS .Mental Illness does not include any condition listed in Appendix G of the DSM-IV,titled"ICD-9-CM Codes for Selected General Medical Conditions and Medication Induced Disorders,"or any comparable li ting if Appen ix G is no longer published. Off-L bel Drug Use: The use of a drug for a purpose other than that for which it was approved by the F A. Origin 1 Aggregate Benefit Effective Date: When We provide You with Aggregate Benefit coverage lunder this Policy or consecutive Policy Years,the Original Aggregate Benefit Effective Date is the date Aggregate enefit covera e first became effective in the consecutive year period. [I O;igin 1 Specific Benefit Effective Date: When We provide You with Specific Benefit coverage under this Policy or consecutive Policy Years,the Original Specific Benefit Effective Date is the date Specific Benefit covera e first became effective in the consecutive year period. Paid: he date Your check or draft for payment of expenses Incurred by a Covered Person is issued and delivered to the payee,provided that the account upon which the payment is drawn contains sufficient funds to and the check dr draft to be honored. Plan:Your self-funded employee benefit plan established to provide benefits to Covered Persons as described in Your p an document.For the purpose of determining benefits payable under this Policy,the Plan shall not include any amendments made to the plan document after the Original Aggregate Benefit Effective Date or the Original Specifi Benefit Effective Date,whichever is earlier,unless We notify You in writing from Our U.S. Headqu ers that We accept the amendment. Pollicyh lder:You,the legal entity to whom this Policy is issued. 11 Prescri tion Drugs: For the purpose of determining Eligible Expenses under this Policy,Prescription Drugs include all prescription drugs covered under Your Plan,other than prescription drugs administered to a Covered Person bile he or she is confined in a hospital or other medical facility. Prescri tion Drug Plan:A benefit provision of Your Plan,or a separate employee benefit plan maintained by You,un er which prescription drug expenses are paid independently of other medical expenses.Expenses incurre under a Prescription Drug Plan will be included as Eligible Expenses only if the Prescription Drug Plan is iriclu ed as a Covered Benefit in the Schedule of Benefits.A Prescription Drug Plan does not mean prescription drug ex enses paid subject to any deductibles and coinsurance applicable to other medical benefits under Ylour Plaii. Provide Network:A Preferred Provider Organization(PPO),Exclusive Provider Organization(EPO),Point of Service lan(POS),self-funded Health Maintenance Organization(HMO),or any managed care network offered under Your Plan. Reimbursement Percentage:The percent of Eligible Expenses that will be considered for reimbursement nder this,Policy. ; Ii 02-SL 2 1 it I Section I 1 i Definitions I Schedule of Benefits:This Policy's schedule of Specific Benefit coverage or Aggregate Benefit coverag- pr1ovided under this Policy. 1 I Speci 1 Risk Questionnaire:A report used to provide Us with certain information We require to underwrite this Policy 1 Third Party Administrator("TPA"):A third party that You have entered into an agreement with to provide admi strative services to Your Plan.Your TPA is not Our agent. Tians s lant:The transplant of organs from human to human.For the purposes of determining Eligible Expenses under is Policy,Transplant includes only the following transplants:heart,heart and lung,lung(single o double ,liver,kidney,pancreas,kidney and pancreas,human bone marrow and stem cell transplantation aid reinfusl on.A Transplant must be performed at a Transplant Facility in order to be considered for reimbursement 11 under d is Policy. Skin and Cornea transplants are not considered a"Transplant"for the purpose of determining Eli gibl- Expenses under this Policy,but are considered Eligible Expenses if covered by your Plan. Trans o lant Facility: A hospital or facility which is accredited by the Joint Commission on Accreditation of Halthi are Organizations to perform a Transplant and: Fo i organ transplants: is an approved member of the United Network for Organ Sharing for such lTran plant or s approved by Medicare as a transplant facility for such Transplant. 1 1 Fo unrelated allogeneic bone marrow or stem cell transplants:is a participant in the National Marrow onor Pr.gram. I1 1 Fo autologous stem cell transplants:is approved to perform such Transplant by:(a)the state where'th 1 Tr.i splant is to be performed; or(b)Medicare;or(c)the Foundation for the Accreditation of Hemopo'etic li Cell Therapy.Outpatient facilities must be similarly approved. Tr at 1 ent:Any treatment,procedure,service,device,supply or drug provided to a Covered Person: 1 Usual .nd Customary Fee:For the purpose of determining Eligible Expenses under this Policy,"Usual"means the fee sually charged for a particular service by a provider;"Customary"means a fee in the range of usual fees charge.'by similar providers in the same geographic area. I U.S.H'adquarters: Our United States headquarters located at One Sun Life Executive Park,Wellesley Hills, Mai 'i usetts. lI 1 11 11 11 II II .I 11 11 02-SL 3 I • 11 11 Section II Benefit Provisions •I Specific Benefit Diefin tions S•ecific Benefit Deductible:The amount of Eligible Expenses relating to a Covered Person that You must p. before You become eligible for a Specific Benefit.The Specific Benefit Deductible is shown on the 1 S• edule of Benefits.In no event will the Specific Benefit Deductible be less than 5%of expected claims or $100,000,whichever is less. S ecific Benefit Lifetime Maximum Reimbursement:The maximum amount We will ever reimburse with re pect to any Covered Person.The Specific Benefit Lifetime Maximum Reimbursement is shown on the Sc edule of Benefits. Speci c Benefit The S ecific Benefit for any Covered Person for any Policy Year equals: 1 1. the total amount of Eligible Expenses for the Covered person;minus 2. the Specific Deductible; m ltiplied by the Reimbursement Percentage shown on the"Schedule of Benefits-Specific Benefit," f that Reimbursement Percentage is less than 100%. The Sp cific Benefit payable with respect to any Covered Person is subject to the Specific Benefit Lifetim- Mximum Reimbursement. III it 1 III 11 I I ' II 1 �'11 ,1 I i I II I it 02-SL 4 it I� Section II Benefit Provisions Aggregate Benefit Defin'tions A gregate Benefit Attachment Point: The amount of Eligible Expenses You must pay during the A gregate B nefit Claims Basis before We will consider an Aggregate Benefit claim.The Aggregate Benefit A achment P Tint is shown on the Schedule of Benefits.In no event will the Aggregate Benefit Attachment Point be less than 120%of expected claims. A gregate Deductible Factor:The deductible factor per Benefit Month per Covered Unit by Covered II Be efit.The Aggregate Deductible Factor for each Covered Benefit is shown on the Schedule of Benefits. A gregate Benefit Maximum Eligible Expenses per Covered Person:The maximum amount,of Eligible Ex enses for any one Covered Person that will be used to calculate the Aggregate Benefit.The Aggregate Be efit Maximum Eligible Expenses per Covered Person is shown on the Schedule of Benefits. M nimum Aggregate Deductible:The minimum amount of Eligible Expenses You must pay before you be ome eligible for an Aggregate Benefit.The Minimum Aggregate Deductible is shown on the Scheule of Be efits. M nthly Aggregate Deductible:The sum of the deductibles for all Covered Benefits for each Benefi: M nth.The deductible for each Covered Benefit is calculated by multiplying the number of Covered Units on the first day of the Benefit Month by the Aggregate Deductible Factor for each Covered Benefit.The cal ulation of the Monthly Aggregate Deductible is subject to the 5%Adjustment Rule. II 5°/ Adjustment Rule: If the Monthly Aggregate Deductible decreases from one month("Month A")to the ne t("Month B"),for any reason,the Monthly Aggregate Deductible for Month B shall not be less th In 95% oft e Monthly Aggregate Deductible for Month A. Aggre ate Benefit i The Ag regate Benefit equals: j 1. the total amount of Eligible Expenses for all Covered Persons,subject to the Aggregate Benefit Maximum Eligible Expenses Per Covered Person;minus the greater of II 2. the Aggregate Benefit Attachment Point or the Minimum Aggregate Deductible; I mu tiplied by the Reimbursement Percentage shown on the"Schedule of Benefits—Aggregate Benefit"if jl1 that Reimbursement Percentage is less than 100%. The Ag regate Benefit will be calculated after the end of the Aggregate Benefit Claims Basis. it Aggreg to Benefit Maximum The Ag;regate Benefit We will pay will not exceed the Aggregate Benefit Maximum shown on the Schedule of il Benefit-. I' Ili 1I II I i i lI 02-SL 5 I it II II II i li Section II Benefit Provisions Expenses Eligible for Reimbursement Eligib e Expenses Eligib e Expenses include any amount paid by You for Medically Necessary and Appropriate expenses incurred 11 by, a overed Person which: ' 1. Have been paid in accordance with the terms of Your Plan; and , 2. Were Incurred and Paid during the applicable claims basis;and 3. Are paid under a Covered Benefit shown on the Schedule of Benefits; and 14. Are not otherwise excluded under this Policy. Alter ative Care In,add tion to satisfying Eligible Expenses criteria 2,3 and 4 above,expenses related to Alternative Care may be consid red Eligible Expenses when all of the following additional criteria have been satisfied: 11 1. You demonstrate to Our satisfaction that providing the Alternative Care resulted in a cost savings to the Plan; I1 and ,. 2. The Alternative Care was recommended by case management services provided to Your Plan;an 13. The Alternative Care was Medically Necessary and Appropriate; and II 4. The Alternative Care was provided with the consent of the Covered Person,or his/her representati e,and with the approval of the Covered Person's licensed health care provider,and was approved by You or Your TPA;and 5. The Alternative Care replaces Treatment that would be covered under Your Plan;and I 6. The Alternative Care expenses do not exceed the maximum allowed under Your Plan for the Trea ent replaced by the Alternative Care;and 1; 7. If the Alternative Care is provided in lieu of inpatient hospitalization,the Covered Person meets utilization review criteria acceptable to Us for inpatient hospitalization for the entire period the Alternative Care is provided.In no event will such Alternative Care that exceeds 90 days be consi ered Eligible Expenses unless approved by Us. Off-La•el Drug Use In addi lion to satisfying the criteria for Eligible Expenses set forth above,expenses related to Off-Label Drug Use may be considered Eligible Expenses when all of the following additional criteria have been satisfied: 11. The drug is not excluded under Your Plan;and 2. The drug has been approved by the FDA; and 3. You can demonstrate to Our satisfaction that the Off-Label Drug Use is appropriate and generally accepted for the condition being treated; and 4. If the drug is used for the treatment of cancer,the American Medical Association Drug Evaluations,The II American Hospital Formulary Service Drug Information,or The Compendia-Based Drug Bulletin, recognize it as an appropriate treatment for that form of cancer. I Reimb rsement of Certain Fees Eligible Expenses will also include the following fees Incurred and Paid by You,when approved by Us at Our U.S.He:dquarters: 1. 'easonable hourly fees for case management services provided by a registered nurse case manager etained by You or Your TPA; and '2. ees for:(a)hospital bill audits; (b)access to non-directed provider networks;and(c)negotiating out of etwork bills. Such fens shall be considered Eligible Expenses only if You can demonstrate to Us that the work which ge erated the fees esulted in a cost savings to the Plan.If the Plan can demonstrate such a cost savings,We will.reimburse You up o 25%of the amount saved. Feed ch ged by Your TPA or any subsidiary of Your TPA for any of these services will be considered Eligible Expense only if prior approval has been obtained in writing from Us at Our U.S.Headquarters. 02-SL 6 II it Section II Benefit Provisions Expenses Eligible for Reimbursement State ealth Care Surcharges IfiYo pay a state health care surcharge imposed by Louisiana,Massachusetts or New York in connectio with the pa ment of Eligible Expenses,such health care surcharges are included as Eligible Expenses.We will only reimb rse health care surcharges imposed by New York if You are registered with the New York Department of Health. l� � I � I � � I II 02-SL 7 i Section II Benefit Provisions Limitations and Exclusions W?e w 11 NOT reimburse You for: 1. E penes for medical services rendered to a Covered Person by the Covered Person's family member or re'ative. 2. E penes relating to an injury or illness arising out of, or occurring during the course of,a Covered Person pe forming any occupation for wage or profit. I 3.� E penes for any cosmetic Treatment as defined in Your Plan.This exclusion does not apply to experses rel ting to breast reconstruction after mastectomy. 'll 4. E enses for any Experimental or Investigational Treatment,or for any hospital confinement or Treatment th t results from Experimental or Investigational Treatment. 5. Ex enses for any transplant not included in the definition of Transplant. 6. Ex enses relating to non-human organ or tissue transplants,gene therapies,xenographs or cloning. 7. Ex enses for any Treatment administered outside the United States if the Covered Person traveled to the II to ation where the Treatment was received for the purpose of obtaining the Treatment. 1 , 8.1 Expenses for benefits in excess of Your Plan's limits,or expenses that are excluded under Your Plan. 9.ii Ex enses in excess of the Usual and Customary Fee. 101 An amount paid by You in excess of a negotiated provider discount,or any penalty or late charge incurred, or ny discount lost,unless previously approved in writing by Us at Our U.S.Headquarters. I 11 it Ex enses associated with the administration of Your Plan including,but not limited to,claim payment fees, co containment administrative fees,PDP administration fees,PPO access fees,premium functions, edical rev ew and consultant fees,unless otherwise covered under this Policy. 12 I Ex s enses paid by You relating to any litigation concerning Your Plan,including,but not limited to,a orneys' i fee.,extra-contractual damages,compensatory damages and punitive damages. 13!'An portion of an expense which You are not obligated to pay under Your Plan,or which is reimbursa.le to Yo under: a) another group health benefit program;or I 1 b) a government or privately supported medical research program;or c) Medicare;or 1 d) any coordination of benefits or non-duplication of benefits provision of Your Plan;or e) worker's compensation;or it f) any other source. 14 J Ex senses for claims submitted to Us that are not submitted in accordance with the Proof of Claim pro .sions oft 's Policy. 15.i Ex.enses incurred by a person who is employed by You at any unit,subsidiary or division of Yours that has II not been underwritten by Us. I 16. Ex senses incurred for any illness or injury due to,or aggravated by,war or an act of war,whether decl red or und-dared. 1 II I 1 02-SL 8 i it III' I i i Section II Benefit Provisions Limitations and Exclusions 17. If Your Plan does not exclude coverage for conditions for which a Covered Person received Treatment within ;I 6 months prior to enrolling in Your Plan,expenses for any such condition will be excluded from ; reimbursement under this Policy for a period of twelve(12)months from the Covered Person's effective date I, der Your Plan(the"12 month period").The 12 month period will be reduced on a month for Monti basis b any"creditable coverage"(as defined in the Health Insurance Portability and Accountability Act of 1996, as amended)attributable to the Covered Person. 18. E Tenses paid by You for any Treatment authorized or approved under any provision of Your Plan which: it a) allows the plan administrator to approve alternative care or alternative treatment; or b) allows the plan administrator to alter,modify,or waive Plan provisions or limitations;or f c) grants You or Your plan administrator discretion to approve coverage for Treatment notl otherwise covered under Your Plan; un ess the Treatment satisfies the criteria for Alternative Care set forth in Section II. 19. E senses covered under a Prescription Drug Plan,unless Prescription Drug Plan coverage is a Covered I� B. efit on the Schedule of Benefits. 20. Exsenses for Treatment of Mental Illness and Drug or Alcohol Dependence will be limited to the lesser of Your Plan's maximum benefit for any such condition or the Specific Benefit Deductible. I IIII � I II 1 �Ij I 1 ' 02-SL 9 � I Il Section III Claim Provisions II I' Proof f Claim Proof f claim must be provided to Us at Our U.S.Headquarters. I Speci c Benefit W itten proof of claim,in a form and content satisfactory to Us,must be provided to Us as soon as reasonably po sible after the Specific Benefit Deductible for a Covered Person has been satisfied.Proof of claim must be 11 pr vided to Us no later than 12 months after the end of the Specific Benefit Claims Basis duringiwhich the cl im arose. Pro of of claim for a Specific Benefit claim shall include the following: 1. a fully completed claim form; 2. a copy of the Covered Person's original enrollment record and records of any change in the Covered Person's coverage under Your Plan; 3. copies of all bills and invoices for expenses submitted for reimbursement under this Policy; 4. proof of payment of any expenses submitted to Us for reimbursement under this Policy;and 5. any additional information We may require to fulfill Our obligations under this Policy. Aggregate Benefit W itten proof of claim,in a form and content satisfactory to Us,must be provided to Us as soon as reasonably Ii po•sible after the end of the Aggregate Benefit Claims Basis for the Policy Year.Proof of claim must he provided to Us no later than twelve(12)months after the end of the Aggregate Benefit Claims Basis. Pr.of of claim for an Aggregate Benefit claim shall include the following: 1. a complete aggregate calculation report; 2. a detailed claims history report for all Eligible Expenses Incurred and Paid during the Aggreg to Benefit Claims Basis; 3. a report listing all Covered Units eligible for benefits under Your Plan at any time during the Aggregate Benefit Claims Basis; 4. a copy of Your Plan in effect during the Policy Year and any amendments thereto; 5. if Prescription Drug Plan coverage is included as a Covered Benefit on the Schedule of Benefits,a copy of all prescription drug invoices and an itemization thereof, including the amounts of an}) rebates received by You;and 6. any additional information We may require to fulfill Our obligations under this Policy. Aplpea of a Claim Determination You m.y appeal any claim determination made by Us under this Policy by submitting a written appeal to s at Our U. S.Headquarters within sixty(60)days from the date of Our determination.Your appeal should stat the basis o i Your disagreement with Our determination and should include all documentation and information support ng Your appeal that has not been previously provided to Us. 1 h An app al of any claim determination made by Us on the grounds that the Treatment provided was: (a);not edically Necessary and Appropriate;(b)cosmetic;or(c)Experimental or Investigational must in lude an Independent Review Panel report which includes each panel member's report and the pan l's II conten us report.The Independent Review Panel report is to be provided at Your expense.The members o the Indepe dent Review Panel must be mutually acceptable to You and Us. Deferr;d Payments by You You m st obtain prior written approval from Us at Our U. S.Headquarters in order for any Eligible Expen es ii Incurre. in the Policy Year,but Paid after the end of the applicable claims basis to be considered eligible fin. rei�inb sement under this Policy. I 1 it i �I 02-SL 10 Section III Claim Provisions Paym nt of Claims All be efits due under this Policy will be paid to You.During the Policy Year,reimbursements will be di bursed when 'he amount payable exceeds$500.00.Any reimbursable amount remaining unpaid at the end of a Policy Year ill be paid after the end of the Policy Year. � I I! I � li I it I I Ij it 1 III I I II II I II 11 I 02-SL 11 Section IV Your Rights and Responsibilities Auth•rizations to Release Information You . e responsible for authorizing Your TPA,Plan Administrator,case manager or other third party service provid-r to release to Us information We request to underwrite,review potential claims,make claim dete inations,calculate potential reimbursements,or perform other obligations under this Policy.If We o not receiv; requested information,it may result in the delay,reduction or denial of a claim. Disclo ure Requirements This Policy has been underwritten based upon the information You provided to Us concerning all persons eligible for benefits under Your Plan on the Original Specific Benefit Effective Date and/or the Original Aggregat Benefit Effective Date(or on the effective date of any class of Covered Persons added thereafter).This ineludes, but is of limited to,those persons who are a special risk as defined in the Special Risk Questionnaire. Your s gnature on the Application for this policy warrants and represents to Us that: 1. You or Your authorized representative have consulted with Your precertification,utilization review and Medical Management Vendors and Your TPA,or former TPA,to determine who must be disclosed as a special risk on the Special Risk Questionnaire;and 2. You have identified any person who is or maybe a special risk by either listing them on the Speci 1 Risk Questionnaire or by indicating any such person on the reports listed on the Special Risk Questionnaire. If You fail to disclose an individual as a special risk,who should have been disclosed as a special risk in accord. ce with the Special Risk Questionnaire,We will have the right to revise the premium rates, deduct ibles, deduct ble factors and terms and conditions of this Policy in accordance with Our underwriting practices i effect at the t me the Policy was underwritten,retroactive to the Original Specific Benefit Effective Date and/or he Original Aggregate Benefit Effective Date. Repor ing Requirements You ar required to provide periodic reports to Us as described below.If You,or Your TPA,do not proui e the reports or do not provide them on a timely basis,We reserve the right,once We receive them,to take whatever action a could have taken if the reports had been provided when required. Such action may include,but}ls not limited to,the right to revise premium rates,deductibles,and deductible factors,and to do so retroactive td the Original Specific Benefit Effective Date and/or the Original Aggregate Benefit Effective Date. Specifi Benefit Reporting Yo ,or Your TPA,are required to provide Us with notice of any potential Specific Benefit claim with n thi -one(31)days of the date: 1. a Covered Person's Eligible Expenses exceed 50%of the Specific Benefit Deductible;or 2. You,Your TPA, or Your medical management,utilization review or precertification vendors, or any other party acting on Your behalf,are notified that a Covered Person has been diagnosed with or treated for,a Catastrophic Diagnosis. Aggre Nate Benefit Reporting Yo ,or Your TPA,are required to provide Us with a monthly report that lists: 1. the total amount of Eligible Expenses Incurred by any Covered Person and Paid by You,or Paid on Your behalf,during the Benefit Month;and 2. the number of each type of Covered Unit on the first day of the Benefit Month. Yo must provide the Aggregate Benefit report to Us within thirty-one(31)days after the end of each enefit M• th. 02-SL 12 ' I Section IV Your Rights and Responsibilities ii Renewal Reporting If You intend to renew this Policy,then three months prior to the end of the Policy Year,You,or Your TPA, an required to provide Us with a report which includes the following information: 1. monthly Paid claims and enrollment data,organized by Covered Benefit; 2. large claim information,including amount,diagnosis and prognosis,and any Covered Person who has been diagnosed with a Catastrophic Diagnosis; 3. a census of all Covered Persons; 4. a summary of the number of Covered Persons by workplace zip code,if this Policy covers Employees at multiple locations; 5. a summary report of precertification,utilization review and case management services; 6. a summary report of Your Provider Network(s)or per diem arrangements,setting forth the average hospital discount or per diem charge per day;and 7. a copy of changes adopted by or proposed for Your Plan. Plan Cihanges You mist notify Us in writing at Our U. S.Headquarters at least thirty-one(31)days before the effective ate of any ch ge in,or to: 1. Your Plan; 1 2. Your TPA; 3. Your Provider Networks; or 4. Your Medical Management Vendors. r � O iur p or written agreement is required before the coverage under this Policy will apply to any such Chan e. Othe ise,benefits under this Policy will be paid based upon the terms of Your Plan as it existed prior to any such c ange.We reserve the right to terminate this Policy as of the effective date of any change in or to Your Plan, our TPA,Your Provider Network,or Your Medical Management Vendor. Notice of Legal Action You ag ee to give Us prompt notice of:(a)any event that might result in a lawsuit relating to this Policy; r(b) any la !suit involving this Policy;and to promptly provide Us with copies of any correspondence and plea! ings reli tin to any such event or lawsuit. Hold armless You ag ee to defend,indemnify and hold Us harmless from and against any and all claims,demands and causes of action f every kind,relating to any litigation,that We,without Our fault,become involved with thatlrelats to this Po icy or Your Plan.You shall pay any and all attorneys' fees,costs,expenses,and damages(including coinpe satory,exemplary or punitive damages)incurred by Us,or payable by Us,in connection with,any uch liti11ati n.This Hold Harmless provision shall not apply to litigation solely between You and Us relating to this Policy. Refun of Overpayment If We, ou,or Your TPA determine that We have overpaid You under this Policy,You will promptly refu-id such overpa ment to Us within 60 days of such a determination.If We are required to take legal action to colle such overpa ment,You agree to indemnify Us for any costs of collection,including,but not limited to,attorney fees and co rt costs. Res po sibility For Your TPA You ar solely responsible for the actions of Your Plan Administrator,Your TPA and any other agent of Y urs. Your T A acts on Your behalf,not on Our behalf.Your TPA is not Our agent.We are not responsible for any coinpe sation owed to,or claimed by,Your TPA or other agents for services provided to,or on behalf of,tour Plan. 's Policy does not make Us a party to any agreement between You and Your TPA,nor does it make Your TP' a arty to this Policy. 02-SL 13 Section IV Your Rights and Responsibilities Right of Recovery You ust pursue all valid claims including,but not necessarily limited to,claims for restitution,constructive trust, :quitable lien,breach of contract, injunction,and any other state or federal law claims You or Your Plan may h.ve against any third party responsible,in whole or in part,for any Eligible Expenses Paid by You. 'You must i mediately advise Us of any amount You recover from them.We reserve the right to pursue any acid all 11 such c aims not pursued by You,and You agree to assign such claims to Us upon Our request. I , i I III 02-SL 14 C ' • �1 I Section V Our Rights and Responsibilities Audit We have the right to inspect and audit any and all of Your records and procedures,and those of Your TPA and any other party,that relate to any claim made by You under this Policy. We have the right to require' documentation from You that demonstrates You paid an Eligible Expense and that the payment was made in accord:nce with the terms of Your Plan.We reserve the right to employ a third party,at Our expense,to assist Us with . y audit function. Deter ination of Eligible Expenses For the purpose of determining Eligible Expenses under this Policy,We have the right to determine whether an expens- was Paid by You in accordance with the terms of Your Plan. Cost Iontainment We ha e the right to retain the services of a Medical Management Vendor, at Our expense,to assist Us wi h cost contai ent when We anticipate that a Covered Person's Eligible Expenses will exceed 50%of the Specific Benefi Deductible during the Policy Year. II , Confi s entiality We wi 1 protect the privacy and confidentiality of all personally identifiable and/or medical information provided to Us ' the course of underwriting or administering this Policy in accordance with Our policies and appli fable state . d federal laws. R Icou.ment We ha e the right to recoup from any benefit payable to You under this Policy any premium You owe to s that has not been paid.Our right of recoupment does not impair Our right to terminate this Policy for non-pay ent of premiu under the Termination Provisions of this Policy. Right o Recalculate We ha e the right to recalculate any Specific Benefit Premium Rate,Specific Benefit Deductible,Aggreg.ting Spiecifi Deductible,Aggregate Benefit Premium Rate,Aggregate Deductible Factor or Minimum Aggreg.to Deduct ble with respect to this Policy Year whenever any one or more of the following events occur:'I ' , 1. Your Plan changes; 2. You change Your TPA,Your Provider Network(s),or Medical Management Vendor(s); 3. this Policy is amended; 4. the number of Covered Units on the first day of a Benefit Month increases or decreases by more t an 15% from the number of Covered Units on the first day of the Policy Year; I 15. the number of Covered Units on the first day of a Benefit Month increases or decreases by more than 10% from the first day of the prior Benefit Month; 6. a unit,division,subsidiary,or affiliated company of Yours is added to,or deleted from,this Polic I; 7. the amount of Eligible Expenses paid in any one of the three(3)months immediately preceding the Policy II Effective Date(the"three month period")exceeds 125%of the monthly average of Eligible Expenses Incurred during the nine(9)months immediately preceding the three month period;or 8. there are changes in Your,or Your TPA's,claim paying system or payment practices that causes a variation of fifteen(15)days or more in the most recent twelve(12)month average of claim processing I time. Any ri t to recalculate exercised under this section may be made retroactive to the Policy Effective Date t Our electio .Any recalculation will be made in accordance with Our underwriting practices in effect at the tim the Policy as underwritten.The right to recalculate shall survive the termination of this Policy. 1' I I i II i ' I 02-SL 15 II ' Section V jl Our Rights and Responsibilities Right •f Reimbursement p rtion of an Eligible Expense which You recover from a third party: Ij 1. is not eligible for reimbursement under this Policy;and 2. cannot be used to satisfy any deductible or attachment point under this Policy;and 3. must be repaid to Us if We previously reimbursed You for it. Any r ayment amount You owe Us may be reduced,with Our consent,by any reasonable and necessary expenses You incurred in obtaining the recovery from the third party.Any repayment amount You owe to Us shall s i rvive the termination of this Policy. I II ii II I , � I ' 02-SL 16 Section VI ,I General Provisions Assig ment Your i terest in this Policy cannot be assigned. I Bank uptcy or Insolvency The b ptcy,insolvency,dissolution,receivership or liquidation of You,Your Plan or Your TPA will not impos upon Us any obligations other than those set forth in this Policy. Cleric 1 Error Ind the vent of a clerical error in this Policy,the Policy will be revised to correct the error.Your failure to: 1. report the existence of a Covered Person;or j 2. file proof of claim in a timely manner;or 3. comply with the reporting requirements of this Policy; shall n t constitute clerical error. Entire Contract Tliis P licy,along with any Attachments,Riders,Endorsements or Amendments,and the Application and Special Risk 9 estionnaire completed by You constitutes the entire contract of insurance between Us. Legal ction You m�y not bring a legal action against Us to recover on this Policy earlier than sixty(60)days after Yo have furors d Us with proof of claim in accordance with the Proof of Claim provisions of this Policy.You ma not bring aiy legal action against Us to recover on this Policy after two(2)years from the time proof of claim is required under this Policy. Misre resentation l' 1. You make any misstatement,omission or misrepresentation,whether intentional or unintentional, in the information or documentation You,Your TPA or any other party acting on Your behalf,provide to Us, and which We rely upon during the underwriting of this Policy;or 11 2. after this Policy is issued,We learn of expenses or claims that were incurred or paid,but not reported to Us,during the underwriting of this Policy; Wle ha e the right,at Our election,to rescind this Policy or to revise the premium rates,deductibles,and terms and co ditions of this Policy in accordance with Our underwriting practices in effect at the time the Policy was uncle ritten.Any such revisions may be made retroactive to the Policy Effective Date. No E SA Liability Under o circumstance will We accept responsibility as a"Plan Administrator"or be deemed a"pin fidu iary" with re pect to Your Plan under the Employee Retirement Income Security Act of 1974,as amended. NoIn-P rticipating Policy This Policy is non-participating and does not share in Our surplus earnings. I�, I Policy mendment No;ch ge in this Policy,or waiver of any of its provisions,will be valid unless such change or waiver is in writing and agreed to by Us at Our U. S.Headquarters and made a part of this Policy.No agent,broker,TPA,or managi g general underwriter has authority to change this Policy or waive any of its provisions. Policy enewal This PoIicy may be renewed on the Policy Anniversary Date unless it has been terminated or is subject to terrain 'don in accordance with the Termination Provisions of this Policy.Policy changes for any renewal policy will ap ear on a revised Schedule of Benefits and/or a Policy amendment. Your payment of the renewal py�emium after re eipt of the revised Schedule of Benefits and/or Policy amendment constitutes acceptance of the renewal policy y You. 02-SL 17 '1 Section VI General Provisions III I. Premium Provisions I Premium Payments Pr mium is due on or before the Premium Due Date. Grace eriod A race period of thirty-one(31)days will be allowed for the payment of each premium due after the first pr mium has been paid.This Policy will continue in force during the grace period.If a premium is no paid by th end of the Grace Period,this Policy will terminate,without notice to You,as of the last date for which pr mium was paid. Premi m Data Yo must provide a report to Us with each premium payment,in a form satisfactory to Us,that lists: 1. the number of each type of Covered Unit,for each Covered Benefit,under Your Plan owthe first day of the Benefit Month;and II 2. the amount of premium paid. W use such premium data reports solely to process premium.They do not replace any report require or liwh ch may be required,under Section IV of this Policy. Severa ility In the : ent that any provision of this Policy is invalidated by a court of competent jurisdiction,all remain' g provisi ens of the Policy shall continue in full force and effect. I Termi ation Provisions ill 1. If You fail to pay the premium,this Policy will terminate in accordance with the Premium Provision of this Policy. 2. If Your Plan is terminated,this Policy will terminate on the date the Plan terminated. 3. If You fail to maintain a minimum of 150 participants in Your Plan at any time during the Policy ear, We may elect to terminate this Policy at the end of the first month during which there are less than 150 participants. 4. This Policy will terminate at the end of the Policy Year unless renewed. 5. If You, or Your TPA,fail to satisfy any of Your obligations under this Policy,We may terminate t is Policy by giving You sixty(60)days advance written notice. 6. We may terminate this Policy within thirty-one(31)days of the end of the Policy Year. 7. You may terminate this Policy at any time by providing Us with 90 days advance written notice at Our . S.Headquarters. Thej p. ies to this Policy may agree in writing to terminate it at any time. Reinsta ement If this P s licy is terminated for non-payment of premium, We may,at Our sole discretion,agree to reinstate C t as of the date it terminated upon payment of all outstanding premium.We may require You to provide certain informa ion to Us before We will consider reinstating the Policy. I Time L mitations If any ti i e limitation in this Policy is less than that permitted by the law of the state in which the Application was taken,the limitation is hereby extended to the minimum period permitted by the law. I ' ,I I iil I I 02-SL 18 jl �j I I II !i Sun Life Assurance Company of Canada SunExcel® Transplant Benefit Rider Effect' e January 1,2005,this Rider is attached to and made part of Stop-Loss Policy No. 69026 issued by Sun Life A surance Company of Canada(the"Policy"). II Intro 8 uction I , The SunExcel®Transplant Benefit provides a number of benefits,which include: • providing Covered Persons with access to Centers of Excellence Transplant Facilities; I • reducing the Specific Benefit Deductible for a Covered Person who uses a Centers of Excellenc Transplant Facility for a Transplant; i • payment of the transplant network access fee; reimbursement for travel and lodging expenses incurred by a Covered Person immediately'prior to,and following,a Transplant if such expenses are covered under Your Plan;and • reimbursement for certain expenses and deductibles paid by the Policyholder. Defini ions program.All capitalized terms used in this Rider shall have the meaning attributed to them by the Policy.For th- p ose of this Rider,the following term shall be defined as follows: Centers of Excellence Transplant Facility:A Transplant Facility We have contracted with,as part of the I SunExcel® Requi ements Toquaify for the SunExcel®Transplant Benefit,You and Your Plan must satisfy all of the following requirements: 1 11. Your Plan must: a) require precertification for Transplant related hospitalizations and outpatient Transplant procedures; I b) offer a minimum Transplant benefit of$300,000.00; I c) treat Centers of Excellence Transplant Facilities as in-network providers;and 1 112. You must: ill a) amend Your Plan to include the SunExcel®Transplant Benefits listed in section 3 and 4 below; I, b) require Your TPA and Provider Network(s)to permit Covered Persons to access SunExcel®Centers of Excellence Transplant Facilities; I li c) advise Your TPA and Medical Management Vendor(s)that Covered Persons may access Cent rs of Excellence Transplant Facilities,and instruct Your TPA and Medical Management Vendor(s)to contact Us at 1-888-4ORGANS when they receive notice that a Covered Person may require a 1, Transplant; ' d) advise Covered Persons that they may access Centers of Excellence Transplant Facilities if they need i a Transplant;and i I, e) agree to waive any exclusion under Your Plan that excludes expenses relating to the acquisition of an organ for a Transplant("organ acquisition expenses"),when organ acquisition expenses are included in the global fee negotiated with a Centers of Excellence Transplant Facility. I i 11 I I I it 02-SL-STBR II' I 1 ' i 1 Sun Life Assurance Company of Canada SunExcel® Transplant Benefit Rider SunE cel®Transplant Benefit If!You satisfy the requirements set forth above,and a Covered Person has a Transplant performed at a Centers of Excell nce Transplant Facility,We will: 1. reduce the Specific Benefit Deductible for the Covered Person by$10,000 for the Policy Year in which the Transplant occurs;and 2. pay any fee required for access to the Centers of Excellence Transplant Facility. In add' ion,if Your Plan provides the following benefits as covered benefits under the SunExcel®Transplant Benefi,Eligible Expenses will include: 3. up to$5,000.00 for any travel and lodging expenses incurred by the Covered Person and one companion immediately prior to,and following,the Transplant;and/or 4. up to$1,500.00 for any deductible and co-payments waived by,or paid to,the Covered Person by Your Plan,for the year in which the Transplant occurs. 1 II ' President Secretary • � I li I III ! 1 ' 11 it 'I I ICI 02-SL-STBR Sun Life Assurance Company of Canada li Endorsement This E dorsement is made part of the Policy to which it is attached. I.ill The Transplant Definition in Section I,"Definitions,"is deleted and replaced by the following:' Transplant:The transplant of organs from human to human,including bone marrow, stem cell . d cord II blood transplants.Transplants include only those transplants that:(a)are approved for Medicare c.verage ' on the date the Transplant is performed;and(b)are not otherwise excluded by this Policy. Ij A Transplant must be performed at a Transplant Facility to be considered for reimbursement unde this Policy. Skin and cornea transplants are not considered a transplant for the purpose of determining I ligible Expenses under this Policy,but are considered Eligible Expenses if covered by Your Plan. ILI'� Item 17 in Section II,"Benefit Provisions—Limitations and Exclusions,"is deleted. y Effecti e Date:January 1,2005 II President Secretary .I II I III I ' I � ' 1,1 .I it I I ' ' I i � I 02-SL-E -1 I: I I� I i I I ; II Sun Life Assurance Company of Canada Endorsement • III This Endorsement is made part of the Policy to which it is attached. II Item 2 rn Section II,"Benefit Provisions-Limitations and Exclusions,"is deleted and replaced by the following: ! 2. Expenses that are payable or reimbursable under any Workers' Compensation Law or similar legislation. Effecti e Date:January 1,2005 III President Secretary II it li p I III , II II I I ' � I 02-SL-E D-2 III i it • I II Sun Life Assurance Company of Canada Amendment No. 1 This • endment is attached to and made part of Stop-Loss Policy No. 69026 issued by Sun Life Assurance Comp.ny of Canada(the"Policy"). I Effecti e January 1,2005,retirees will not be included as Covered Persons under this Policy,except for those reiree• as stated in Appendix A[Appendix A attached]. II; I President Secretary I III I it I I'II 1 ,I lil II ii i 'li I II i 1 I I ! .I li I 02-SL-A I ND III Sun Life Assurance Company of Canada Endorsement This E dorsement is made part of the Policy to which it is attached. 1 The Covered Person definition in Section I,"Definitions,"is deleted and replaced by the followin_: Covered Person:A person enrolled in Your Plan and entitled to receive benefits under Your Plan during the Run-In Period or while this Policy is in force. Retirees,as defined by Your Plan,may be Covered II Persons if they are included on the Schedule(s)of Benefits. II The Dependent definition in Section I,"Definitions",is deleted and replaced by the following: Dependent: A person enrolled in Your Plan and entitled to receive benefits under Your Plan as a dependent of a Covered Person. If the law of the state where the Policy is issued requires that domestic partners be covered under Your Plan,then individuals who are domestic partners under the law'shall be considered Dependents under the Policy. The State Health Care Surcharges provision in Section II,"Benefit Provisions-Expenses Eligible for Reimbursement"is deleted and replaced by the following: State Health Care Surcharge If You pay a state health care surcharge imposed by Louisiana,Massachusetts or New York in connection with the payment of Eligible Expenses,such health care surcharges are included as Eligible Expenses.We II will only reimburse health care surcharges imposed by New York up to 8.85%of the amount upon which the surcharge was levied. I141 The following provision is added to Section II,"Limitations and Exclusions": [21]. Notwithstanding any other Policy provision,We will not reimburse any expense incurred by any I' employee,or by the employee's dependents,where the employee is a member of:(a)a'division, unit,group,subsidiary,affiliate,or class of employee of the Policyholder;or(b)an association, trust,cooperative or similar organization connected with the Policyholder,that is not covered by the Plan as of the Policy Renewal Effective Date. Ii V. The Grace Period provision in the"Premium Provisions"of Section VI,"General Provisions"is deleted and replaced by the following: ' Grace Period A grace period of forty-five(45)days will be allowed for the payment of each premium due after the first premium has been paid.This Policy will continue in force during the grace period.If a premium is not paid by the end of the Grace Period,this Policy will terminate,without notice to You,as Hof the last date for which premium was paid. VI.ii Item 3 of the Termination Provisions in Section VI,"General Provisions"is deleted and replaced by the ollowing: li 'I c. If You fail to maintain a minimum of 100 participants in Your Plan at any time during the Policy Year,We may elect to terminate this Policy at the end of the first month during which there are less than 100 participants. 02-SL-E -3 Page 1 of 2 1I�11 III Sun Life Assurance Company of Canada Endorsement III VII. Item 7 of the Termination Provisions in Section VI,"General Provisions"is deleted and replaced 'y the II following: 7. You may terminate this Policy at any time by providing Us with 31 days advance written notice at our U.S.Headquarters. Effective Date:January 1,2007 I ' /10 . II President Secretary II II I1 'I III , I III i i I I 02-SL-EIND-3 Page 2 of 2 I ' II I I II ►`i4. � Stop Loss Benefits Sun Life Assurance Sun SC-3221 Company of Canada II Li a Financial" One Sun Life Executive 'ark Wellesley Hills,MA 624:1-5699 Feel ru. 8,2007 City o Renton 1055 S.uth Grady Way Renton WA 98055 ,I Attn:T rri Shuhart RE:Po icy Number 69026 Dear M . Shuhart: In resp nse to your recent request,we have amended the above policy,effective January 1,2007. li For you convenience,we have reissued the policy to include the requested changes in a single document.Please review he enclosed policy,which replaces your present policy.This policy is reissued from the Amendment Effecti e Date to reflect the changes indicated below. I Amend ent Effective Date Description of Change January 1,2007 Renewal Policy Year, Specific Benefit Lifetime Maximum Reimbursement, Specific Benefit Premium Rate,Aggregate Deductible Factor("ADF"),Minimum 11 II Aggregate Deductible and Endorsement No. 3 added it Except stated in this Amendment,nothing contained herein shall be held to alter or affect any of the policy provisio s,including any prior amended policies,amendments,modifications,addendums,endorsements, attachm nts or riders thereto. We appr-ciate this opportunity to assist you. li Sincerel , 1' Stoj-Lo•s Benefits cc: Sean e Group Office I I SLPC 10419 03 Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies. �II www.sunlife-usa.com I � 1 ill )111I Sun `� PRIVACY POLICY Life Financial' I nitro'action At the Sun Life Financial group of companies,'protecting your privacy is important to us. Whether you are . existing customer or considering a relationship with us,we recognize that you have an interest in how e may collect,use and share information about you. Sun i fe Financial has a long tradition of safeguarding the privacy of its customers' information. e under tand and appreciate the trust and confidence you place in us, and we take seriously our obli ation to maintain the confidentiality and security of your personal information. We invite you to review this Privacy Policy which outlines how we use and protect that information. Cone ation of Nonpublic Personal Information by Sun Life Financial Colle ting personal information from you is essential to our ability to offer you high-quality investment, retire.sent and insurance products. When you apply for a product or service from us,we need to obtain info ation from you to determine whether we can provide it to you. As part of that process,we may co'llec information about you,known as nonpublic personal information, from the following sources: • Information we receive from you on applications or other forms, such I as your name, address, social security number and date of birth; • Information about your transactions with us, our affiliates or others, such as other life insurance policies or annuities that you may own; and 1. • Information we receive from a consumer reporting agency, such as a credit report. Limit d Use and Sharing of Nonpublic Personal Information by Sun Life Financial We us- the nonpublic personal information we collect to help us provide the products and services you have r-quested and to maintain and service your accounts. Once we obtain nonpublic personal info ation from you,we do not disclose it to any third party except as permitted or required by law. We m iy share your nonpublic personal information within Sun Life Financial to help us develop innovative financial products and services and to allow our member companies to inform you about them. The S Life Financial group of companies provides a wide variety of financial products and services inelud. g individual life insurance,individual fixed and variable annuities and group life,disability and medic 1 stop-loss insurance. 1 For a omplete list of the Sun Life Financial member companies that have adopted this Privacy Policy,please see the rev rse side of this Notice. II We also may disclose your nonpublic personal information to companies that help in conducting oiir busin ss or perform services on our behalf, or to other financial institutions with which we have joint mark ting agreements. Sun Life Financial is highly selective in choosing these companies, and weI requi e them to comply with strict standards regarding the security and confidentiality of our customl ers' nonp blic personal information. These companies may use and disclose the information provided to tlem my for the purpose for which it is provided, as permitted by law. Ther also may be times when Sun Life Financial is required to disclose its customers' nonpublic perso al information, such as when complying with federal, state or local laws,when responding t a subp ena,or when complying with an inquiry by a governmental agency or regulator. £ur reatment of Information About Former Customers Our p otection of your nonpublic personal information extends beyond the period of your customer relati nship with us. If your customer relationship with us ends,we will not disclose your inform tion to nona filiated third parties other than as permitted or required by law. Security of Your Nonpublic Personal Information I We aintain physical, electronic and procedural safeguards that comply with federal and state regul tions to safeguard your nonpublic personal information from unauthorized use or improper access. Emp yee Access to Your Nonpublic Personal Information 1 We r strict access to your nonpublic personal information to those employees who have a busines1 need tO kn w that information in order to provide products or services to you or to maintain your accouits. Our e ployees are governed by a strict code of conduct and are required to maintain the confidentiality of cu tomer information. it The llowing Sun Life Financial companies have adopted this Notice. Other Sun Life Financial affili ted companies have adopted their own privacy policies. Please check their websites for details. Insur•nce Companies Distributors/Broker-Dealers/Underwriters ' Stun Lii e Assurance Company of Canada(U.S.operations) Clarendon Insurance Agency,Inc. Sun Lii e Assurance Company of Canada(U.S.) IFMG of Oklahoma,Inc. Sun Lip e Insurance and Annuity Company of New York IFS Agencies,Inc. hidep: dence Life and Annuity Company IFS Agencies of Alabama,Inc. Ieypo Life Insurance Company IFS Agencies of New Mexico,Inc. IFS Insurance Agencies of Ohio,Inc. IFS Insurance Agencies of Texas,Inc. Independent Financial Marketing Group,Inc. Keyport Financial Services Corp. IFMG Securities,Inc. LSC Insurance Agency of Arizona,Inc. LSC Insurance Agency of Nevada,Inc. LSC Insurance Agency of New Mexico,Inc. ISLPC10523 03/03