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Loss caused by or relating to a Pre-existing Condition is not covered for the first 12 months after the Certificate Effective Date of each Covered Person.
This Policy provides Limited Benefits. Policy Form SL-EMPDI 16 is not available in all states and benefits may vary. The policy has specific terms and conditions relating to coverage, including limitations and exclusions. Not yet available in the following states: AK, CO, CT, FL, MA, MN, ND, NM, VT, WA
PRE-EXISTING CONDITION LIMITATION:
Loss caused by or relating to a Pre-existing Condition is not covered for the first 12 months after the Certificate Effective
Date of each Covered Person [unless the optional Pre-Existing Condition Benefit is selected]. ]
No benefits are paid for disability which results from a Covered Person’s:
• intentionally self-inflicted Injury or attempted suicide, while sane or insane;
• commission of, or attempt to commit, a felony;
• the voluntary or involuntary administration, taking or ingestion of any drug, sedative or narcotic unless taken as
prescribed by a Physician;
• engaging in an illegal occupation;
• involvement in any period of armed conflict, even if it is not declared;
• participation in a riot;
• riding in or driving any motor-driven vehicle in a race, stunt show or speed test;
• operating, learning to operate, serving as a crew member/employee of or jumping or falling from any aircraft, including those
which are not motor driven. This does not include flying as a fare-paying passenger[.] [;]
• [Substance Abuse;]
• [Mental Illness. However, Alzheimer’s disease and other organic senile dementias are covered.]
We will also not pay for disability occurring within the first ten (10) months of coverage when the disability
directly arises from a Covered Person’s pregnancy. Disability resulting from Complications of Pregnancy will be
covered as a sickness.
ENTIRE CONTRACT; CHANGES
The Policy, the Application(s), the Riders (if any), and any attached papers make up the entire contract between the
Employer and the Company.
In the absence of fraud, all statements made by the member/employee or covered Spouse will be considered representations and
not warranties. No written statement made by the member/employee or covered Spouse will be used in any contest unless a copy
of the statement is furnished to the member/employee or his/her Beneficiary or personal representative.
No change in the Policy will be valid until approved by an executive officer of the Company. The approval must be
attached to the Policy. No agent may change the Policy or waive any of its provisions.
The Company may amend or change the Policy by written agreement with the Employer. We may amend or change the
Certificate at any time, without the consent of the Employer, the member/employee, any Covered Person or beneficiary, if required
by law. Any amendment will be without prejudice to any charge incurred prior to the effective date of the change.
TIME LIMIT ON CERTAIN DEFENSES
Misstatements in the Enrollment Form - After 2 years from the Certificate Effective Date, no misstatements, except
fraudulent misstatements, made by the member/employee or a covered Spouse in the Enrollment Form for coverage will be used
to void the coverage or to deny a claim for loss incurred or disability (as defined herein) commencing after the expiration
of the two-year period.
Pre-Existing Conditions - No claim for loss or disability (as defined herein) commencing after 12 months from a Covered
Person’s Certificate Effective Date will be reduced or denied on the grounds that a disease or physical condition not
excluded from coverage by name or specific description effective on the date of loss had existed before the Certificate
CONFORMITY WITH STATE STATUTES
Any provision of the Policy which, on its effective date, is in conflict with the statutes of the state in which the Employer is
located is hereby amended to conform to the minimum requirements of those statutes.
EXAMINATION OF THE POLICY
The Group Policy will be available for inspection at the Employer’s office during regular business hours.
The Employer has established and maintains an member/employee welfare benefit plan as defined in the member/employee Retirement
Security Act of 1974, as amended, to provide the benefits described in the Policy to its member/employees and their Dependents.
These benefits are insured by Us under the Policy, which the Employer endorses. The Employer is the Plan Administrator,
Plan Sponsor, named fiduciary, and, if applicable, Plan Trustee, for the Plan. For more information about the plan, consult
the Policy. ERISA does not apply to certain plans, such as government plans and church plans.
NOTICE OF CLAIM
A claimant must give the Company written notice of a claim. It should be given within 60 days after the occurrence or
commencement of any loss covered by the Policy, or as soon thereafter as is reasonably possible. Notice given by a
claimant or on behalf of a claimant to Us at our Home Office, or to any authorized agent of the Company, with information
sufficient to identify the claimant, will be deemed notice to the Company.
The Company will send the claimant a claim form when a notice of claim is received. If the form is not furnished within 15
days from the time the claimant gives notice, he/she may fulfill the proof of loss requirements by sending written proof
covering the occurrence, the character and the extent of the loss for which claim is made within the time set in Proof of
PROOF OF LOSS
The claimant must give the Company written proof of loss within 90 days after such loss. If it is not reasonably possible to
do so, the Company will not reduce or deny the claim for being late if proof is given as soon as reasonably possible. It
must, however, be given within 15 months from the date of loss, unless the claimant is not legally capable. Written proof
of loss, provided at your expense, means a completed claim form or other documentation that includes:
• the date and description of an accident, if applicable;
• your employer’s statement verifying your last day of work, job title, job duties, your normal work schedule, and the
return to work date, if any; and
• your attending doctor’s statement verifying dates of treatment, diagnosis, dates you were restricted from performing
your job, and the applicable restrictions and limitations.
If You are self-employed when You become Totally Disabled, We will require that You provide a valid business license
and filed federal tax returns as proof You are self-employed. We also reserve the right to require verification of any such
information that You provide. We also reserve the right to have You examined by an authorized Company representative.
Any additional proof that We require, such as medical records, will be at Our expense.
EVIDENCE OF CONTINUING DISABILITY
Once We approve Your claim, You will be asked to provide evidence of continuing disability at reasonable intervals based
on Your condition. Evidence of continuing disability means documentation of Your condition that is sufficient to allow Us to
determine if You are still disabled. If You do not submit evidence of continuing disability when requested, Your payments
You must give us proof of continuing disability no later than 90 days after the end of a period for which We may owe You
benefits. Upon receipt of evidence of continuing disability, benefit payments will resume subject to the terms of this
TIME OF PAYMENT OF CLAIMS
Benefits payable under the Policy for any loss other than loss for which the Policy provides any periodic payment will be
paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued
indemnities for loss for which the Policy provides periodic payment will be paid monthly and any balance remaining unpaid
upon the termination of liability will be paid immediately upon receipt of due written proof.
PAYMENT OF CLAIMS
Benefits for loss of life will be payable in accordance with the Beneficiary designation and the provisions respecting such
payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then
effective, such benefits will be payable to the estate of the claimant. Any other accrued indemnities unpaid at the
claimant’s death may, at Our option, be paid either to such Beneficiary or to such estate. All other indemnities will be
payable to the claimant.
If any benefit is payable to the estate of the claimant, or to a claimant or Beneficiary who is a minor or otherwise not
competent to give a valid release, We may pay such indemnity up to an amount not exceeding $2,500 to any relative by
blood or connection by marriage of the claimant or Beneficiary who is deemed by Us to be equitably entitled thereto. Any
payment made by Us in good faith pursuant to this provision will fully discharge Us to the extent of such payment.
An Employee may assign all of his/her rights, privileges and benefits under the Policy without the consent of his/her
designated Beneficiary. The Company is not bound by an assignment until the Company receives and files a signed
copy. The Company is not responsible for the validity of assignments. The assignee only takes such rights as the
assignor possessed and such rights are subject to state and federal laws and the terms of the Policy.
CHANGE OF BENEFICIARY
The right to change a Beneficiary is reserved for the Employee, and the consent of the Beneficiary or beneficiaries is not
required for the surrender or assignment of the benefits, for any change of Beneficiary or beneficiaries, or for any other
changes in the coverage.
PHYSICAL EXAMINATIONS AND AUTOPSY
The Company may have a Covered Person examined at its own expense as often as it may reasonably require while their
claim is pending under the Policy and to make an autopsy in case of death where it is not forbidden by law.
No action at law or in equity shall be brought to recover under the Policy for at least 60 days after the member/employee has given
the Company written proof of loss in accordance with the requirements of the Policy. The member/employee cannot start such
action more than 3 years after the date proof of loss is required to be furnished.
RIGHT OF RECOVERY
When an overpayment has been made by Us, We will have the right to: a) recover that overpayment from the person to
whom or on whose behalf it was made; or b) offset the amount of that overpayment from a future claim payment.
Actively-At-Work or Active Work means You, the member/employee, who is present for at least [19-30] hours per week at Your
usual place of employment for the Employer or at another location as assigned or directed by the Employer, and is
mentally and physically capable of performing the regular duties of Your Job.
On any day that is not one of Your regularly scheduled work days (vacation, personal days, and weekends/holidays), You
will be considered Actively-at-Work on such day provided You are not absent due to any type of leave and were Actively-
At-Work on Your last regularly scheduled work day.
If You are an member/employee who usually performs the regular duties of Your Job at Your home, You are considered Actively-
At-Work if you meet all of the above requirements and could work at the Employer’s usual place of employment if required
to do so.
If Your Spouse is covered under Your Certificate this definition applies as to his/her employer.
Activities of Daily Living means the following:
1. Dressing means putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs;
2. Toileting means getting to and from the toilet, getting on and off the toilet, and performing associated personal
3. Transferring means the ability to move in or out of a chair, bed or wheelchair;
4. Eating means feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table); or
5. Preparing meals.
Age means a Covered Person’s Age as of his/her last birthday.
Calendar Year means a period of 12 consecutive months starting on January 1 and ending on December 31 of the same
Certificate Effective Date is the date coverage begins for each Covered Person under the Policy. It will be different for a
Covered Person added to the Policy after the original date of issue or when a change in coverage for any Covered Person
occurs. Each Covered Person’s Certificate Effective Date is shown in the member/employee’s Certificate Schedule of Benefits.
Complications of Pregnancy means:
1. Conditions, requiring Hospital Confinement (when the pregnancy is not terminated), whose diagnoses are distinct
from pregnancy but are adversely affected by pregnancy, including, but not limited to, acute nephritis, nephrosis,
cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable severity, but
does not include false labor, pre-term or premature labor, occasional spotting, physician prescribed rest during the
period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions associated
with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and
2. Non-elective cesarean section, termination of ectopic pregnancy, and spontaneous termination of pregnancy,
occurring during a period of gestation in which a viable birth is not possible.
Covered Accident means an unintended and unforeseen injurious occurrence causing Injury which:
1. Occurs while this Certificate is in force; and
2. Is not excluded by name or specific description.
Covered Person means an member/employee or an member/employee’s Spouse, listed in the Certificate Schedule of Benefits and for
whom premium has been paid.
Covered Sickness means illness, disease, Complications of Pregnancy or pregnancy, which:
1. Occurs while this Certificate is in force; and
2. Is not excluded by name or specific description.
Elimination Period means the number of continuous days a Covered Person must be Totally Disabled before benefits
begin. The Elimination Period may be different for disabilities due to Sickness than it is for Injury. The Elimination
Periods are shown on the Certificate Schedule of Benefits.
member/employee means the member/employee designated in the Enrollment Form [who is [Actively-At-Work and] listed in an eligible
class of member/employees in the Employer’s application]. The member/employee must be listed as a Covered Person in the Certificate
Schedule of Benefits and appropriate premium paid in order to be covered under the Policy. [An member/employee does not
include seasonal or temporary member/employees.]
Employer means the entity or plan sponsor to whom the Group Policy is issued and shall include any affiliated entities or
subsidiaries approved by the Company.
Enrollment Form means the form(s) that You signed to apply for coverage under the Policy. It also includes any other
document approved by the Company that You use to change coverage under the Policy.
Gross Annual Income means the full dollar amount, before any payroll deductions, of: wages; salaries; overtime pay;
bonuses; and tips. It does not include: fees; interest income; dividend income; real property income; personal property
income; retirement funds income; investment income; unemployment earnings; child support payments; alimony
payments; or other compensations for personal services actually rendered.
Hospital means an institution licensed to operate as a Hospital pursuant to the law of the state in which it is located. The
term "Hospital" does not include any institution or part thereof used as a rehabilitation unit or rehabilitation facility; a
hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility;
an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial or educational care, care or
treatment for persons suffering from Mental Illness, care for the aged, or care for persons addicted to drugs or alcohol.
Injury or Injuries means an accidental bodily injury sustained that results from a Covered Accident. It does not include
sickness, disease or bodily infirmity. Overuse syndromes, typically due to repetitive or recurrent activities, such as
osteoarthritis, Carpal Tunnel Syndrome or tendonitis, are considered to be a sickness and not an injury for purposes of
Inpatient or Confinement means confined overnight as a registered bed patient in a Hospital or other medical facility
where at least one day’s room and board is charged. This definition does not include a Covered Person’s treatment in an
ambulatory surgical center, emergency room, or an observation room.
Maximum Benefit Period means the longest period of time for which benefits will be paid for Total Disability as shown on
the Schedule of Benefits.
Mental Illness means any disorder, regardless of its cause or medical origin, which is classified as a mental illness or
disorder by the International Classification of Diseases. Diagnoses include, but are not limited to: neurosis,
psychoneurosis, psychopathy, psychosis, mental or emotional disease, bipolar affective disorder or autism. Diagnoses do
not include those that are classified as Substance Abuse, substance dependency or mental illness or disorders induced
by Substance Abuse.
Off-The-Job means a Covered Person that is not Actively-at-Work.
On-The Job means a Covered Person that is Actively-at-Work.
Off-The-Job Injury means an Injury that occurs while a Covered Person is not Actively-at-Work.
On-The Job Injury means an Injury that occurs while a Covered Person is Actively-at-Work.
Open Enrollment means the period of time each year in which You can sign up for health insurance. The Open
Enrollment sign up period is set by Your Employer.
Outpatient means a Covered Person who is not confined as Inpatient in a Hospital.
Partial Disability/Partially Disabled means a Covered Person who can perform some, but not all of the duties of his/her
Policy means the Group Policy, including any attached applications, riders, endorsements that describe Your benefits.
Physician means a person, other than a Covered Person, a close relative, or a business or professional partner who is:
1. Duly licensed to practice medicine in the jurisdiction where the medical diagnosis is made, or the procedure
performed where such jurisdiction is a continuing member/member/employee of the United States of America or a territory within the
jurisdiction of the United States of America (embassies, military zones, and similarly designated non-domestic
extension of the United States government are not included); and
2. Acting within the scope of his/her license.
[Pre-existing Condition means a condition for which medical advice, diagnosis, care or treatment were received or
recommended by a Physician within 12 months before the Certificate Effective Date. ]
Retired means that an individual has permanently ended his/her working/professional career and is receiving retirement
and/or pension-type benefits such as: Social Security Retirement; company pension; government pension; military pension;
401K plan; and/or Individual Retirement Account (IRA).
Spouse means the person to whom the member/employee is legally married.
Substance Abuse means psychological or physical dependence on, or addiction to, alcohol, drugs or any other
controlled substances characterized by:
1. Impairments in social and/or occupational functioning;
2. Debilitating physical condition;
3. Inability to abstain from or reduce consumption of the substance; or
4. The need for daily substance use to maintain adequate functioning.
Substance Abuse includes alcohol and drugs, but excludes caffeine and tobacco.
Totally Disabled, Total Disability or Disability means while Your Certificate is in force, a Covered Person is:
1. Unable to perform Your Job or in the case of the covered Spouse, his/her job;
2. Not working for pay or benefits; and
3. Under the regular care of a Physician for an Injury or Covered Sickness causing such Total Disability, unless in the
opinion of a Physician, future or continued treatment would be of no benefit.
[After [24-60] months of disability, Total Disability means You are unable to work in any occupation for which you are
suited by training, education, or experience.]
For an unemployed Covered Person Totally Disabled means the inability to perform two or more of the five
Activities of Daily Living while under the regular and appropriate care of a Physician.
We, Our, Us, or Company means Standard Life and Accident Insurance Company.
You or Your or Yours means the member/employee listed in the Application for the Policy.
Your Job/Job means the substantial and material duties of the Active Work that You are engaged in at the time You
become Totally Disabled.
If Your Spouse is covered under Your Certificate this definition applies as to his/her job.