Dental Services - Accidental Injury (Emergency Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.
Harassment Complaint Procedures In the case of a complaint of either personal or sexual harassment, the following shall apply:
ACCIDENTAL DAMAGE IN HANDLING ( “ADH”): If purchased, the Covered Product is protected against accidental damage in handling such as drops and liquid spills. Immersion of Your Covered Product is not covered under this Agreement. ADH only covers operational or mechanical failure caused by a single incident while handling and does not include protection against theft, mysterious disappearance, misplacement, viruses or reckless, abusive, willful or intentional misconduct associated with handling and/or use of the Covered Product, cosmetic damage and/or other damage that does not affect the unit’s functionality, damage caused during shipment between You and Our service providers and any other limitations listed in the “What is Not Covered” section of this Agreement. For the purpose of this Agreement, Accidental Damage is defined as a single, unexpected, sudden and unintentional event and does not include accumulated damage from continual or multiple events. The use of this coverage requires an explanation of where and when the Accidental Damage occurred as well as a detailed description of the actual event. If needed, the replacement value of the Covered Product will be solely determined by the Administrator of this Agreement.
Basic Life and Accidental Death and Dismemberment Coverage The Employer agrees to provide and pay for the following term life coverage and accidental death and dismemberment coverage for all supervisors eligible for an Employer Contribution, as described in Section 3. Any premium paid by the State in excess of fifty thousand dollars ($50,000) coverage is subject to a tax liability in accord with Internal Revenue Service regulations. A supervisor may decline coverage in excess of fifty thousand dollars ($50,000) by filing a waiver in accord with Minnesota Management & Budget procedures. The basic life insurance policy will include an accelerated benefits agreement providing for payment of benefits prior to death if the insured has a terminal condition. Supervisors’ Annual Base Salary Group Life Insurance Coverage Accidental Death and Dismemberment Principal Sum $10,000 - $15,000 $15,000 $15,000 $15,001 - $20,000 $20,000 $20,000 $20,001 - $25,000 $25,000 $25,000 $25,001 - $30,000 $30,000 $30,000 $30,001 - $35,000 $35,000 $35,000 $35,001 - $40,000 $40,000 $40,000 $40,001 - $45,000 $45,000 $45,000 $45,001 - $50,000 $50,000 $50,000 $50,001 - $55,000 $55,000 $55,000 $55,001 - $60,000 $60,000 $60,000 $60,001 - $65,000 $65,000 $65,000 $65,001 - $70,000 $70,000 $70,000 $70,001 - $75,000 $75,000 $75,000 $75,001 - $80,000 $80,000 $80,000 $80,001 - $85,000 $85,000 $85,000 $85,001 - $90,000 $90,000 $90,000 Over $90,000 $95,000 $95,000
Prohibition Against Selecting and Installing Products Containing Hazardous Materials The Contractor shall not select, install or otherwise incorporate any products or materials containing Hazardous Materials within the boundaries of the Site. Should the Contractor or any Subcontractors have knowledge that, or believe that, an item, component, material, substance, or accessory within a product or assembly selected by the Contractor or any Subcontractor may contain Hazardous Materials it is the Contractor’s responsibility to secure a written certification from the manufacturer of any suspected material which identifies the specific Hazardous Material(s) contained, together with the Material Safety Data Sheets (MSDS) for such materials which shall be submitted to the Owner and Design Professional.
Accidental Death and Dismemberment Coverage An employee may purchase accidental death and dismemberment coverage that provides principal sum benefits in amounts ranging from five thousand dollars ($5,000) to one hundred thousand dollars ($100,000). Payment is made only for accidental bodily injury or death and may vary, depending upon the extent of dismemberment. An employee may also purchase from five thousand dollars ($5,000) to twenty-five thousand dollars ($25,000) in coverage for his/her spouse, but not in excess of the amount carried by the employee.
CLAIM PROCEDURES Claim forms or claim information as to the subject policy can be obtained by contacting Benmark, Inc. (800-544-6079). When the Named Fiduciary has a claim which may be covered under the provisions described in the insurance policy, they should contact the office named above, and they will either complete a claim form and forward it to an authorized representative of the Insurer or advise the named Fiduciary what further requirements are necessary. The Insurer will evaluate and make a decision as to payment. If the claim is payable, a benefit check will be issued in accordance with the terms of this Agreement. In the event that a claim is not eligible under the policy, the Insurer will notify the Named Fiduciary of the denial pursuant to the requirements under the terms of the policy. If the Named Fiduciary is dissatisfied with the denial of the claim and wishes to contest such claim denial, they should contact the office named above and they will assist in making an inquiry to the Insurer. All objections to the Insurer's actions should be in writing and submitted to the office named above for transmittal to the Insurer.
Convicted, Discriminatory, Antitrust Violator, and Suspended Vendor Lists In accordance with sections 287.133, 287.134, and 287.137, F.S., the Contractor is hereby informed of the provisions of sections 287.133(2)(a), 287.134(2)(a), and 287.137(2)(a), F.S. For purposes of this Contract, a person or affiliate who is on the Convicted Vendor List, the Discriminatory Vendor List, or the Antitrust Violator Vendor List may not perform work as a contractor, supplier, subcontractor, or consultant under the Contract. The Contractor must notify the Department if it or any of its suppliers, subcontractors, or consultants have been placed on the Convicted Vendor List, the Discriminatory Vendor List, or the Antitrust Violator Vendor List during the term of the Contract. In accordance with section 287.1351, F.S., a vendor placed on the Suspended Vendor List may not enter into or renew a contract to provide any goods or services to an agency after its placement on the Suspended Vendor List. A firm or individual placed on the Suspended Vendor List pursuant to section 287.1351, F.S., the Convicted Vendor List pursuant to section 287.133, F.S., the Antitrust Violator Vendor List pursuant to section 287.137, F.S., or the Discriminatory Vendor List pursuant to section 287.134, F.S., is immediately disqualified from Contract eligibility.
Accidental Death and Dismemberment Insurance The plan provides accidental death and dismemberment insurance coverage in an amount equal to your basic group life insurance (two times your current annual salary). Coverage is provided 24 hours per day, anywhere in the world, for any accident resulting in death, dismemberment, paralysis, loss of use, or loss of speech or hearing. If you sustain an injury caused by an accident occurring while the policy is in force which results in one of the following losses, within 365 days of the accident, the benefit shown will be paid to you. In the case of accidental death, the benefit will be paid to the beneficiary you have named to receive your group life insurance benefits. Benefits are payable in accordance with the following schedule: Schedule of Benefits 100% of Principal Sum For Loss of: · Life · Both Hands or Both Feet · Entire Sight of Both Eyes · One Hand and One Foot · One Hand and Entire Sight of One Eye · One Foot and Entire Sight of One Eye · Speech and Hearing in Both Ears · Use of Both Arms or Both Legs or Both Hands · Quadriplegia (total paralysis of both upper and lower limbs) · Paraplegia (total paralysis of both lower limbs) · Hemiplegia (total paralysis of upper and lower limbs of one side of the body) 75% of Principal Sum For Loss of: · One Arm or One Leg · Use of One Arm or One Leg 66 2/3% of Principal Sum For Loss of: · One Hand or One Foot · Entire Sight of One Eye · Speech or Hearing in Both Ears · Use of One Hand or One Foot 33 1/3% of Principal Sum of Loss of: · Thumb and Index Finger of One Hand · Four Fingers of One Hand
Transportation of Accident Victims Transportation to the nearest physician or hospital for employees requiring medical care as a result of an on-the-job accident shall be at the expense of the Employer.
