Dental Limit policy wording for Generali Global Assistance Preferred

MEDICAL AND DENTAL COVERAGE

We will pay this benefit, up to the amount on the Schedule, for the following covered expenses incurred by you, subject to the following:

1. Covered expenses will only be payable at the Usual and Customary level of payment; and

2. Benefits will be payable only for covered expenses resulting from a Sickness that first manifests itself or an Injury that occurs while on a Trip; and

3. Benefits payable as a result of incurred covered expenses will only be paid after benefits have been paid under any Other Valid and Collectible Health Insurance in effect for you. This coverage is in excess to any other health insurance you have available to you at the time of the loss. You must

submit your claim to that provider first. Any benefits you receive from your primary or supplementary insurance providers will be deducted from your claim with us.

Covered Expenses:

1. Expenses for the following Physician-ordered medical services: services of legally qualified Physicians and graduate nurses, charges for Hospital confinement and services, local ambulance services, prescription drugs and medicines, and therapeutic services, incurred by you within one year from the date of your Sickness or Injury during a Trip; and

2. Expenses for emergency dental treatment incurred by you during a Trip up to the amount in the Schedule.

Your duties in the event of a Medical or Dental Expense:

1. You must provide us with all bills and reports for medical and/or dental expenses claimed.

2. You must provide any requested information related to the claimed expense(s), including but not limited to, an explanation of benefits from any other applicable insurance.

3. You must sign a patient authorization to release any information required by us, to investigate your claim.

Please refer to the Definitions, for an explanation of Pre- Existing Conditions, which are excluded under the Medical or Dental Expense Benefits.

Coordination of Benefits

If you reside in CT, ID, IL, and excess coverage for Medical and Dental Expense Benefits is not permitted, then coordination of benefit provisions in accordance with the laws and regulations in your state will apply in lieu of the excess coverage provisions.

Coordination of Benefits

1. Applicability

A. This Coordination of Benefits (“COB”) provision applies to This Policy when you or your covered dependent has health care coverage under more than one Policy. “Policy” and “This Policy” are defined below.

B. If this COB provision applies, the order of benefit determination rules should be looked at first. Those rules determine whether the benefits of This Policy are determined before or after those of another policy. The benefits of This Policy:

i. Will not be reduced when, under the order of benefit determination rules, This Policy determines its benefits before another Policy; but

ii. May be reduced when, under the order of benefit determination rules, another policy determines its benefits first.

2. Definitions

A. “Policy” is any of these which provides benefits or services for, or because of, medical or dental care or treatment:

i. Policy will include:

1. group insurance and group subscriber contracts;

2. uninsured arrangements of group or group type coverage;

3. group or group type coverage through HMOs and other prepayment, group practice and individual practice policies;

4. group type contracts. Group type contracts are contracts which are not available to the general public and can be obtained and maintained only because of membership in

or connection with a particular organization or group. Individually underwritten and issued guaranteed renewable policies would not be considered group type even though purchased through payroll deductions at the premium savings to the Insured since the Insured would have the right to maintain or renew the Policy independently of continued employment with the Policyholder;

5. the medical benefits coverage in group automobile no-fault contracts, and in traditional automobile fault type contracts to the extent that such contracts are Primary Policies; and

6. Medicare or other governmental benefits, except as provided in subsection (ii)(7) below. That part of the definition of Policy may be limited to the hospital, medical and surgical benefits of the governmental program.

ii. Policy will not include:

1. individual or family insurance contracts;

2. individual or family subscriber contracts;

3. individual or family coverage through Health Maintenance Organizations (HMOs):

4. individual or family coverage under other prepayment, group practice and individual practice policies;

5. group or group type hospital indemnity benefits

of $100.00 per day or less;

6. school Accident type coverages; these contracts cover grammar, high school and college students for Accidents only, including athletic injuries, either on a 24 hour basis or on a to and from school basis; and

7. state policy under Medicaid, and will not include a law or policy when, by law, its benefits are in excess of those of any private insurance policy or other non-government policy.

Each contract or other arrangement for coverage under (i) or (ii) is a separate policy. Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate policy.

B. “This Policy” is this Policy.

C. “Primary Policy/Secondary Policy” – The order

of benefit determination rules state whether This Policy is a Primary Policy or a Secondary Policy as to another policy covering the person.

When This Policy is a Primary Policy, its benefits are determined before those of the other policy and without considering the other policy’s benefits.

When This Policy is a Secondary Policy, its benefits are determined after those of the other policy and may be reduced because of the other policy’s benefit.

When there are more than two policies covering the person, This Policy may be a Primary Policy as to one or more other policies, and may be a

Secondary Policy as to a different policy or policies.

D. “Allowable Expense” means a necessary, reasonable and customary item of expense for health care; when the item of expense is covered at least in part by one or more policies covering the person for whom the claim is made. When a policy provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an Allowable Expense and a benefit paid.

The following are examples of expenses or services that are not allowable expenses:

i. If an Insured Person is confined in a private hospital room, the difference between the cost of a semi-private room in the hospital and the

private room (unless the patient’s stay in a private room is medically necessary in terms of generally accepted medical practice, or one of the policies routinely provides coverage for hospital private rooms) is not an allowable expense.

ii. If a person is covered by two or more plans that compute his/her benefit payments on the basis of usual and customary fees, any amount in excess of the highest of the usual and customary fees for a specific benefit is not an allowable expense.

iii. If a person is covered by two or more plans that provide benefits or services on the basis of negotiated fees, any amount in excess of the

highest of the negotiated fees is not an allowable expense.

iv. If a person is covered by one plan that calculates its benefits or services on the basis of usual and customary fees and another plan that provides its benefits or services on the basis of negotiated fees, the primary policy’s payment arrangements will be the allowable expense for all policies.

v. The amount a benefit is reduced by the primary policy because an Insured Person does not comply with the policy provisions. Examples of  these provisions are second surgical opinions, pre-certification of admissions or services and preferred provider arrangements.

E. “Claim Determination Period” means a calendar year. However, it does not include any part of a year during which a person has no coverage under This Policy, or any part of a year before the date this COB provision or a similar provision takes effect.

3. Order of Benefit Determination Rules

A. General – When there is a basis for a claim under This Policy and another policy, This Policy is a Secondary Policy which has its benefits determined after those of the other policy, unless:

i. The other policy has rules coordinating its

benefits with those of This Policy; and

ii. Both those rules and This Policy rules, in

Sub-section B below, require that This Policy’s benefits be determined before those of the other policy.

B. Rules – This Policy determines its order of benefits using the first of the following rules which applies.

i. Non-Dependent – the benefits of the policy which covers the person as a subscriber (that is, other than as a dependent) are determined before those of the policy which covers the person as a dependent.

ii. Dependent Child/Parents not Separated or Divorced – except as stated in paragraph B(iii) below, when This Policy and another policy cover the same child as a dependent of different persons, called “parents”:

1. The benefits of the policy of the parent whose birthday falls earlier in a year are determined before those of the policy of the parent whose birthday falls later in that year, but

2. If both parents have the same birthday, the benefits of the policy which covered one parent longer are determined before those of the policy which covered the other parent for a shorter period of time.

However, if the other policy does not have the rule described in (1) immediately above, but instead has a rule based upon the gender of the parent, and if, as a result, the policies do not agree on the order of benefits, the rule

in the other policy will determine the order of

benefits.

iii. Dependent Child/Separated or Divorced Parents – If two or more policies cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order:

1. First, the policy of the parent with custody of the child;

2. Then, the policy of the spouse of the parent with the custody of the child; and

3. Finally, the policy of the parent not having custody of the child.

However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the Policy of that parent has actual knowledge of those terms, the benefits of that Policy are determined first. The Policy of the other parent will be the Secondary Policy. This paragraph does not apply with respect to any Claim Determination Period or Policy Year during which any benefits are actually paid or provided before the entity has that actual knowledge.

iv. Joint Custody – If the specific terms of a court decree state that the parents will share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the policies covering the child will follow the order of benefit determination rules outlined in paragraph B(ii).

v. Active/Inactive Member – The benefits of a policy which covers a person as an employee who is neither laid off nor retired are determined before those of a policy which covers that person as a laid off Member. The same applies if a person is a dependent of a person covered as a Member. If the other policy does not have this rule, and if, as a result, the policies do not agree on the order of benefits, this Rule (v) is ignored.

vi. Continuation Coverage – If a person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another policy, the following will be the order of benefit determination:

1. First, the benefits of a policy covering the person as a Member or subscriber (or as that person’s dependent);

2. Second, the benefits under the continuation

coverage.

If the other policy does not have the rule described above, and if, as a result, the policies do not agree on the order of benefits, this rule is ignored.

vii. Longer/Shorter Length of Coverage – If none of the above rules determines the order of

benefits, the benefits of the policy which covered

a Member or subscriber longer are determined

before those of the Policy which covered that person for the shorter term.

4. Effect on the Benefits of This Policy

A. When this Section Applies – this Section 4 applies when, in accordance with Section 3, “Order of Benefit Determination Rules”, This Policy is a Secondary Policy as to one or more other policies. In that event, the benefits of This Policy may be reduced under this section. Such other policy or policies are referred to as “the other policies” in 4(B) immediately below.

B. Reduction in This Policy’s Benefits – The benefits

of This Policy will be reduced when the sum of:

i. The benefits that would be payable for the Allowable Expenses under This Policy in the absence of this COB provision; and

ii. The benefits that would be payable for the Allowable Expenses under the other policies, in the absence of provisions with a purpose like that of this COB provision, whether or not claim is made; exceeds those Allowable Expenses in a Claim Determination Period. In that case, the benefits of This Policy will be reduced so that they and the benefits payable under the other policies do not total more than those Allowable Expenses. When the benefits of This Policy are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of This Policy.

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