Out-of-Pocket Protection Plan

• Helps pay deductibles and co-payments.

• You choose benefits and premiums.
• Pays benefits directly to you unless assigned to help with
hospital bills and out-of-pocket costs.
• Pays in addition to all other insurance and workers’
compensation.

This is a Hospital Confinement Protection Insurance Policy

Underwritten by Family Life Insurance Company and
ManhattanLife Assurance Company of America / fka Central United Life Insurance Company

ManhattanLife SM

C-GAP15 0916 Since 1850 Not available in all states.

OUT-OF-POCKET PROTECTION PLAN

With today’s rising cost of medical care and health insurance premiums,
many individuals and groups have selected higher deductibles, fewer
co-pays and more out-of-pocket costs. This has been done to make health
insurance premiums more affordable.*
*National Center Biotechnology information.

But, out-of-pocket costs may still cause unnecessary burdens on many

individuals.

What’s the solution?

THE NEW OUT-OF-POCKET PROTECTION PLAN!

• Pays directly to you, unless you assign your benefits to your
provider(s).
• Your choice of benefits and premiums.
• Pays in addition to all other insurance.
• No deductibles.
• No networks.
 How Our Plan Works
Once you have met the requirements, fill out the necessary claims form and
attach your itemized statement.
It’s that easy!

Benefits can be paid in a lump sum directly to you!

DAILY INPATIENT HOSPITAL CONFINEMENT
BENEFIT** (per hospital admission)
You may choose a daily inpatient
If you are confined in a hospital as a resident inpatient* benefit of either:
Pays the daily inpatient benefit you select (maximum of
MANDATORY BENEFITS

10 days) (in TX, 31 days) per hospital confinement. In FL, q $ 100 a day
payable for first 20 days of confinement then $10/$20
for next 11 days - depending on benefit level selected. q $ 200 a day
This benefit is not payable for the treatment of Mental/
Nervous disorders and substance abuse.
You may choose your hospital
HOSPITAL ADMISSION BENEFIT admission benefit below
(1 per year) q $ 2,500
If you are admitted to a hospital as a resident inpatient*
Pays the Hospital Admission Benefit you selected.
q $ 5,000
q $ 6,350
DOCTOR OFFICE VISIT (2 per year) $ 50
You may choose a
OUTPATIENT SURGERY BENEFIT*** benefit of either:
(2 per year)
q $ 1,000
OPTIONAL BENEFITS

For surgical services rendered in an Ambulatory Surgical

Center or Outpatient Hospital Facility, pays the amount q $ 2,000
you selected for outpatient surgery.
q $ 3,000
EMERGENCY ACCIDENT BENEFIT
(4 per year) (FL maximum 2 per year)
If you sustain an injury which requires emergency care
by a physician in a emergency room or urgent care
$ 250
facility, pays the amount per emergency treatment. The Maximum benefit per injury
treatment must be received within 72 hours of the injury.
In FL, this benefit is payable only if you are confined as an
inpatient within 24 hours of emergency treatment.
* Confined as a resident inpatient means assigned to a hospital bed for an overnight stay for medically
necessary reasons resulting from injury or illness on the advice of a physician
** A day is a 24 hour period where room and board is charged
***Refer to policy for limitations on this benefit
Conditionally renewable to age 69 (in CA, age 65) - Your Policy cannot be canceled regardless of
changes in health or the number of times benefits are received. You have the right to renew this Policy
until the earliest of when You become insured under Medicare or attain age 69 (in CA, age 65) if You pay
the correct premium when due or within the Grace Period. The Company reserves the right to change
the rates on all policies of this class in the entire state.
 This brochure is designed to give a brief description of the policies and optional benefits and does not constitute a
contract. The exact terms, limitations, exclusions definitions, conditions and qualifications of a specific procedure or
service will be found in the policy delivered to you. The terms of the policy govern.
TEN-DAY RIGHT TO RETURN
If, You are not satisfied, return the Policy to Us or Our agent within 10 (in CA and KY, 30) days after You have received it. All
premiums will be refunded, and Your coverage will be void from the Effective Date. In OK, if We do not return any premium or
moneys paid within 30 days from the date of cancellation, We will pay interest on the proceeds.
PRE-EXISTING CONDITIONS
This Policy does not cover Pre-Existing Conditions whether disclosed in the application or not, for the first 12 (in NM and NV, 6)
months beginning on the date that person becomes an Insured on this Policy or Rider. In NC, however, for any Insured over 65
years of age at the time this Policy is issued, Pre-Existing Conditions are only those conditions specifically eliminated by rider.
Conditions specifically named or described as excluded in any part of this Policy are never covered.
By Pre-Existing Conditions, we mean:
• those conditions for which medical advice or treatment was received or recommended or that could be medically documented; and
• conditions or symptoms that would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment,
within the 12 (in NV, 6) months period immediately preceding the Policy Effective Date.

EXCLUSIONS AND LIMITATIONS - This Policy provides benefits only for losses identified in the Hospital Confinement and Other Fixed Indemnity Benefits
section. We will not pay benefits for claims resulting, whether directly or indirectly, from events or loss related to or resulting from any of the following: a. except
in MI and SD, being intoxicated or under the influence of any controlled substance unless prescribed by a physician. In IL, being legally intoxicated as defined
and determined by the laws of the jurisdiction where the loss or cause of the loss was incurred, or being under the influence of any drug unless prescribed by
a physician, or being under the influence of any over-the-counter drug unless administered in accordance to the manufacturer’s instructions. In MO, being
intoxicated or under the influence of any narcotic unless administered on the advice of a physician. In OK, being under the influence of any narcotic unless
administered on the advice of a physician. In TN, any loss sustained or contracted in consequence of the Insured being intoxicated or under the influence of
any narcotic unless administered on the advice of a physician; b. attempted suicide while sane or insane (in MO, insane does not apply) or any willful and
intentional act by the Insured to purposely cause harm or damage to him-/herself; c. being exposed to war or any act of war, declared or undeclared (in FL,
except for acts of terrorism against the general population) (in NC, and acts of terrorism occurring outside the country for which the Policy is issued) or while
serving in the armed forces or auxiliary units thereto, including the National Guard or Army Reserve (in OK, including while working in an area of war whether
voluntarily or as required by an employer.); d. the Insured’s commission of or attempt to commit a felony or to which a contributing cause was the Insured’s
being engaged in an illegal occupation. In SD, the Insured’s commission of a felony at the time of loss; e. except in TX, cosmetic Service dental treatment
or dental surgery. This exclusion does not apply if the treatment or surgery is: (1) due to an Injury; or, (2) to restore normal bodily functions or create a normal
appearance as a result of congenital defects, developmental abnormalities, trauma, infection, tumors, or disease (in IL, except infections which result from an
accidental injury or infections which result from an accidental, involuntary or unintentional ingestion of a contaminated substance); f. care that is primarily for
rest, convalescence, or rehabilitation; g. treatment of Mental or Nervous Disorders without demonstrable organic disease; h. treatment which is rendered
outside the United States, its possessions, or Canada, except for emergency care for acute onset of a covered Sickness or Injury or combination thereof
sustained while traveling for business or pleasure; i. except in GA, SD and TX, any Pre-Existing Conditions as defined in this Policy; j. except in FL and TX,
conditions specifically excluded by amendment or endorsement; k. except in TX, cosmetic Service surgery. This exclusion does not apply if the surgery is:
(1) due to an Injury; or (2) to restore normal bodily functions or create a normal appearance as a result of congenital defects, developmental abnormalities,
trauma, infection, tumors, or disease (in IL, except (infections which result from an accidental injury or infections which result from an accidental, involuntary
or unintentional ingestion of a contaminated substance), tumors, or disease). (3) devices or surgery to restore or achieve symmetry incident to mastectomy,
including coverage for all complications including lymphedema; l. except in AZ, MO and TX, being incarcerated in a penal institution or government detention
facility; m. except in OK and TX, driving any taxi for wage, compensation, or profit; n. except in OK and TX, operating, learning to operate, or serving as a
crew member of any aircraft; o. except in IL, OK and TX, engaging in hang-gliding, hot air ballooning, bungee jumping, parachuting, scuba diving, sail gliding,
parasailing, parakiting, or any similar activities; p. except in IL,OK and TX, riding in or driving any motor-driven vehicle in a race, stunt show, or speed test; or,
q. except in IL, OK and TX, officiating, coaching, practicing for, or participating in any semi-professional or professional competitive athletic contest for which
any type of compensation or remuneration is received.
TERMINATION - You may cancel this Policy at any time by sending Us written notice. Upon cancellation, We will return the unearned portion of any premium
paid. This Policy will terminate at 12:01 a.m. local time at Your state of residence on the earliest of the following date: 1. The end of the month You attain age
69 (in CA, 65); 2. The date You are insured under Medicare; 3. The date We receive a request in writing to terminate this Policy or on a later date that is
requested by You for termination; 4. The date this Policy lapses for nonpayment of premium subject to the Grace Period provision in the Premium Provision
section; 5. except in ND, the date We terminate or nonrenew all individual marketed hospital indemnity insurance Policies in the state in which this Policy was
issued or the state in which You presently reside. We will give You (in IL, 90 days) advance notice, as required by state law, of the termination of Your coverage.
In FL, the date all policies the same as this one are non-renewed in the state in which this Policy was issued or the state in which You presently reside. We will
give You at least 180 days advance written notice, as required by state law, of the non-renewal of Your coverage; or, 6. The date You move to a state where
We do not provide insurance under a Policy with the same Policy design as this Policy, We reserve the right to terminate this coverage.
Except in AR, coverage of a Covered Dependent will terminate on: 1. The date We receive a request in writing to terminate coverage for a Covered Dependent
or on a later date that is requested by You for termination of a Covered Dependent; or, 2. The date a Covered Dependent no longer meets the Covered
Dependent definition in this Policy. We will pay benefits to the end of the time for which We have accepted premiums. If coverage terminates due to Your
death, Your spouse (in CA and NV, domestic partner) will become the named Policyholder provided Your spouse (in CA and NV, domestic partner) is a Covered
Person under this Policy on the date of death. When such Insured’s insurance ends, We will consider any claim that began before the insurance ended.
Delay or failure to report termination of any insurance will not continue the insurance in force beyond the date it would have terminated according to this Policy.

THIS HOSPITAL INDEMNITY INSURANCE PLAN IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT
A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER
MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.
Underwritten by:
Policy Form Numbers: C-GAPJ15, C-GAPJ15-LA, C-GAPJ15-OK, ManhattanLife Assurance Company of America
C-GAPJ15-TX; F-GAPJ15 (including state variations) 10777 Northwest Freeway, Houston, TX 77092
Toll Free Telephone: 800-669-9030