POLICY SERVICES

PO BOX 926169
HOUSTON TX 77292

BUSINESS WORKERS OF AMERICA INC

3030 NW EXPRESSWAY STE 200
MAILBOX 610
OKLAHOMA CITY OK 731125466
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 ManhattanLife Insurance and Annuity Company
Administrative Office: 10777 Northwest Freeway, Houston, TX 77092 855-448-6982
Home Office: Houston, TX

GROUP HOSPITAL CONFINEMENT AND OTHER FIXED INDEMNITY INSURANCE POLICY

ISSUED TO POLICYHOLDER: BUSINESS WORKERS OF AMERICA INC
POLICY NUMBER: 890978-W39MGAF1
EFFECTIVE DATE: August 1, 2023 POLICY RENEWAL DATES: August 01
PREMIUMS PAYABLE: Monthly
SITUS STATE: Oklahoma
This Policy is a legal contract between ManhattanLife Insurance and Annuity Company (“Company”) and
the Policyholder. All the terms on this page and the following are part of this Policy.

The insurance offered by the Company is shown on the Application for this Policy. Insurance chosen by
the Policyholder and issued by the Company is shown on the Schedule of Benefits. Insurance on
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Covered Persons is shown in their Certificates.

This Policy may be renewed on each Policy Renewal Date by agreement between the Company and the
Policyholder. Any change in the terms will be shown on an amendment, an endorsement or amended
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Schedule.
This Policy is non-participating. This means that it will not share in the Company’s profits or surplus
earnings. The Company will pay no dividends on it.
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This Policy is issued in and governed by the laws of the Situs State, shown in the Schedule above.
The Policy Application may have been captured electronically or on paper. Please carefully review
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answers to questions on the Application. Make sure that they are answered correctly. If an error exists,
please tell Us immediately.
Signed for the Company
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John McGettigan, Secretary Tyler Harris, President

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THIS IS A LIMITED POLICY. READ IT CAREFULLY.

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THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. IF MEMBERS ARE ELIGIBLE FOR MEDICARE,
REVIEW THE “GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH MEDICARE” AVAILABLE FROM THE
COMPANY.

GROUP HOSPITAL CONFINEMENT AND OTHER FIXED INDEMNITY

INSURANCE POLICY

NON-PARTICIPATING

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TABLE OF CONTENTS
SCHEDULE OF BENEFITS ............................................................................................ 3
ELIGIBILITY .................................................................................................................... 4
BENEFITS....................................................................................................................... 5
BENEFIT CONDITIONS, LIMITATION AND EXCLUSIONS ........................................... 6
CLAIM PROVISIONS .................................................................................................... 10
PORTABILITY ............................................................................................................... 11
TERMINATION OF INSURANCE – COVERED PERSONS ......................................... 13
POLICY RENEWAL, AMENDMENT AND TERMINATION ........................................... 14
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PREMIUM PROVISIONS .............................................................................................. 14

GENERAL PROVISIONS .............................................................................................. 15
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DEFINITIONS ............................................................................................................... 17
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SCHEDULE OF BENEFITS

Calendar Year 08/01 - 12/31

Lifetime Maximum Benefit $5,000,000

HOSPITAL BENEFITS Plan 1

Inpatient Hospital Confinement Benefit $100 per day

Max 10 days per confinement

Intensive Care Unit Confinement Benefit $200 per day

Max 10 days per Confinement

Hospital Benefits Calendar Year Maximum $1,000,000

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First Day Hospitalization Benefit $1,000

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Max 1 day per Calendar Year

Emergency Room Benefit $200 per day

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Max 1 day per Calendar Year

Ambulance Benefits
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Ground $100 per trip

Air $100 per trip

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Maximum for Ambulance Benefits 1 trip per Calendar Year

Office Visit Benefit $50

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Max 3 day per Calendar Year

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Wellness Visit Benefit $50 per day

Max 1 day per Calendar Year

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 ELIGIBILITY

Classes of Eligible Members: Classes of Eligible Dependents:

All Members Spouses of Insured Eligible Members
Children of Insured Eligible Members

Eligibility Requirements for Eligible Members

In order to Enroll, an Eligible Member must be Actively at Work (Active Employment):
For All Members Actively At Work means 20 hours per week
Waiting Periods for Eligible Members are as follows:

All Members are Eligible to Enroll after Active Employment for 0 days
However, if an eligible Member is not Actively At Work at the end of the waiting period, the waiting period
will be extended until the eligible Member resumes work in a pattern that will establish Active
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Employment.
Eligible Members must be between the Ages of 18-70. The max renewal age is 70. However, the Member
who remains Actively at Work after Age 70 will remain an Eligible Member.
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Additional Eligibility Requirements for Eligible Dependents

Waiting Periods for Eligible Members apply to their eligible Dependents.
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Spouses must be between the Ages of 18-70. A Spouse who is an Eligible Member may be covered as
an Member or a Covered Dependent, but not both.
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Children must be at least Age 0 days but not more than Age 25. A child who is an Eligible Member may
be covered as an Member or a Covered Dependent, but not both.
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EFFECTIVE DATE
The Policy’s Effective Date is shown on the face page of this Policy.
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The Certificate Effective Date is shown on the face page of the Certificate.
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A Member’s insurance will be effective on the date shown on the face page of the Certificate provided the
Member is then Actively at Work. Coverage starts at 12:01 AM local time where the Member lives.
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1. If a Member is not Actively at Work on the date coverage would otherwise become effective, the
Effective Date of this coverage will be the date on which such Member is first thereafter Actively
at Work.
The Certificate Effective Date for a Spouse and/or children coverage is the date shown on the face page
of the Certificate Schedule subject to the following:
1. The date the Member’s insurance is effective for a Spouse and/or children who are eligible on
that date, for whom coverage is applied for and premium paid and who is not Hospital confined.
Coverage starts at 12:00 AM local time where the Member lives.
2. On the day a Spouse and/or child is no longer Hospital confined if the Spouse and/or children
were otherwise eligible for coverage on the date the Member’s insurance became effective, for

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 whom coverage was applied for and premium paid for the Spouse and/or children. Coverage
starts at 12:00 AM local time where the Member lives.
3. For a Spouse and/or children eligible on or first acquired after the Member’s Effective Date, the
Effective Date will be the date We assign after approving the enrollment form for such coverage.
If approved, coverage starts at 12:00 AM local time where the Member lives.
4. Children who are born, adopted, or placed for adoption with the Member after this coverage has
been issued are covered for 31 days from the moment of live birth or the date of adoption or
placement. If the Member does not have children coverage at the time of birth, adoption, or
placement, the Member must notify Us within these 31 days. Additional premium will apply. If the
Member already has children coverage, there may be no additional premium charge.
EFFECTIVE DATES FOR CHANGES IN AMOUNTS OF INSURANCE
Increases in amounts of insurance requested by the Member will occur on the first day of the calendar
month following approval of the change request.
Decreases in amounts of insurance requested by the Member will occur on the first day of the calendar
month following approval of the change request.
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BENEFITS

Benefits selected by the Policyholder and approved by the Company are shown on the Schedule of
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Benefits.
Benefits available to Covered Persons are shown in their Certificates.
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Benefits shown on a Certificate issued under this Policy are available to the Covered Persons:
• who meet this Policy’s eligibility requirements to Enroll for the benefits;
• who are Enrolled for the benefits;
• who are covered under the terms and conditions of this Policy for the benefits; and
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• for whom premiums are paid.

All benefits of this Policy are subject to the Benefit Conditions, Limitations and Exclusions provision.
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Inpatient Hospital Confinement Benefit

We will pay this per day benefit for each day there is a charge for Inpatient room and board during a
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Confinement Period under the orders of a Health Care Practitioner for care of Sickness or Injury. Benefits
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under this provision are not payable when the confinement is in a Rehabilitation Unit due to Sickness or
Injury. This benefit is not paid in addition to the Hospital Observation Benefit or Intensive Care Unit
Hospital Confinement Benefit. This Benefit is subject to the Hospital Benefits Calander Year Maximum.

Intensive Care Unit Confinement Benefit

We will pay this per day benefit for each day a Covered Person is confined, and there is a charge for
room and board for one of the following:
• an Intensive Care Unit (ICU);
• a Cardiac Care Unit; or
• a Burn Unit.

This benefit is not paid in addition to the Hospital Observation Benefit or Inpatient Hospital Confinement
Benefit. This Benefit is subject to a per day and the Hospital Benefits Calendar Year Maximum.

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First Day Hospitalization Benefit

We will pay this benefit for the first day a Covered Person is admitted as Inpatient during a Calendar
Year. If one Period of Confinement spans parts of two Calendar Years, only one benefit is payable. This
benefit is subject to a Calendar Year Maximum.

Emergency Room Benefit

We will pay this per day benefit for each day a Covered Person receives care in an Emergency Room.
This benefit is subject to a Calendar Year Maximum.

Ground or Air Ambulance Benefits

We will pay this per trip benefit when ground or air transportation in an ambulance is used by a Covered
Person who needs Emergency Treatment for Sickness or Injury. This benefit is subject to a Calendar
Year Maximum.
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Office Visit Benefit

We will pay this per day benefit when a Covered Person receives covered health care in a Health Care
Practitioner's office for Sickness or Injury. Office Visits are subject to a Calander Year Maximum. This
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benefit is not payable in addition to the Wellness Visit Benefit.

Wellness Visit Benefit

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We will pay this per day benefit when a Covered Person undergoes a Wellness Visit with a Health Care
Practitioner. This benefit is subject to a Calendar Year Maximum. This benefit is not payable in addition to
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the Office Visit Benefit.

PRE-EXISTING CONDITIONS LIMITATION

We will not pay benefits for events that result from or are related to a Pre-Existing Condition, or its
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complications, until the Covered Person has been continuously insured under their Certificate for 12
months. After this period, benefits will be available for Covered Events resulting from or related to a Pre-
Existing Condition, or its complications, provided the Covered Event occurs while the Policy and a
Covered Person’s Certificate is in force.
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BENEFIT CONDITIONS, LIMITATION AND EXCLUSIONS

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This Policy provides benefits only for Covered Events identified in the 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:
1. A Sickness or Injury that is the result of a work-related condition that is eligible for benefits under
Worker’s Compensation, Employers’ Liability, or similar laws even when the Covered Person
does not file a claim for benefits. This exclusion will not apply to a Covered Person who is not
required to have coverage under any Worker’s Compensation, Employer’s Liability, or similar law
and does not have such coverage. However, the Covered Person must receive services in
accordance with the Hospital Confinement and Other Fixed Indemnity Benefits section.
2. A Sickness or Injury that takes place outside of the United States.
3. War or any act of war, whether declared or undeclared, while serving in the military or an auxiliary
unit attached to the military or working in an area of war whether voluntarily or as required by an
employer.
4. Participation in the military service of any country or international organization.

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 5. Treatment, services, or supplies that:
a. are not part of a specifically listed Covered Event shown on the Schedule of Benefits;
b. are due to complications of a non-covered service;
c. are incurred before the Covered Person’s Effective Date or after the termination date of
coverage, except as provided under the Extension of Benefits provision in the Other
Provisions section; or,
d. are provided in a student health center or by or through a school system.
6. Glasses, contact lenses, vision therapy, exercise or training, surgery, including any complications
arising therefrom, to correct visual acuity including, but not limited to, lasik and other laser
surgery, radial keratotomy services or surgery to correct astigmatism, nearsightedness (myopia)
and/or farsightedness (presbyopia), and vision care that is routine.
7. Hearing care that is routine, any artificial hearing device, cochlear implant, auditory prostheses or
other electrical, digital, mechanical, or surgical means of enhancing, creating, or restoring
auditory comprehension.
8. Treatment/services for foot conditions including, but not limited to:
a. flat foot conditions;
b. foot supportive devices, including orthotics, and corrective shoes;
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c. foot subluxation treatment;

d. corns, bunions, calluses, toenails, fallen arches, weak feet, chronic foot strain, or
symptomatic complaints of the feet; or
e. hygienic foot care that is routine.
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9. Dental treatment, dental care that is routine, bridges, crowns, caps, dentures, dental implants or
other dental prostheses, dental braces or dental appliances, extraction of teeth, orthodontic
treatment, odontogenic cysts, any other treatment or complication of teeth and gum tissue, except
as otherwise covered for an Accidental Injury.
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10. Treatment of TMJ and CMJ, any appliance, medical or surgical treatment for malocclusion (teeth
that do not fit together properly which creates a bite problem), protrusion or recession of the
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mandible (a large chin which causes an underbite or a small chin which causes an overbite),
maxillary or mandibular hyperplasia (excess growth of the upper or lower jaw) or maxillary or
mandibular hypoplasia (undergrowth of the upper or lower jaw).
11. Treatment of Mental or Nervous Disorders or Substance-Related Disorders, whether organic or
non-organic, chemical or non-chemical, biological or non-biological in origin and irrespective of
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cause, basis or inducement, including, but not limited to, drugs and medicines for Inpatient or
Outpatient treatment of Mental or Nervous Disorders or Substance-Related Disorders.
12. Any treatment, services, supplies, diagnosis, drugs, medications or regimen, whether medical or
surgical, for purposes of controlling the Covered Person’s weight or related to obesity or morbid
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obesity, whether or not weight reduction is Medically Necessary or appropriate or regardless of

potential benefits for co-morbid conditions, weight reduction or weight control surgery, treatment
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or programs, any type of gastric bypass surgery, suction lipectomy, physical fitness programs,
exercise equipment or exercise therapy, including health club membership visits or services, and
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nutritional counseling.
13. Organ, tissue, or cellular material donation by a Covered Person, including administrative visits
for registry, computer search for donor matches, preliminary donor typing, donor counseling,
donor identification, and donor activation.
14. Chemical peels, reconstructive or plastic surgery that does not alleviate a functional impairment
and other confinement or treatment visits primarily for a Cosmetic Service as determined by Us.
15. Capsular contraction, augmentation, or reduction mammoplasty, except for all stages and
revisions of reconstruction of the breast following a Medically Necessary mastectomy for
treatment of Cancer, including reconstruction of the other breast to produce a symmetrical
appearance and treatment of lymphedemas.
16. Removal or replacement of Durable Medical Equipment or Personal Medical Equipment, except
for internal breast prostheses following a Medically Necessary mastectomy for treatment of
Cancer and services are received in accordance with the Hospital Confinement and Other Fixed
Indemnity Benefits section.

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 17. Prophylactic treatment, services, or surgery including, but not limited to, prophylactic mastectomy
or any other treatment, services, or surgery to prevent a disease process from becoming evident
in the organ or tissue at a later date.
18. Treatment, services, and supplies for:
a. Home Health Care;
b. Hospice care;
c. Skilled Nursing Facility care, Inpatient Rehabilitation Unit services;
d. Custodial Care, respite care, rest care, supportive care, homemaker services;
e. phone, facsimile, internet or e-mail consultation, compressed digital interactive video,
audio or clinical data transmission using computer imaging by way of still-image capture
and store forward;
f. treatment, services, or supplies furnished primarily for the personal comfort or
convenience of the Covered Person, Covered Person’s family, a Health Care
Practitioner, Chiropractor or other provider;
g. treatment or services provided by a standby Health Care Practitioner; or
h. treatment or services provided by a masseur, masseuse or massage therapist or Rolfing.
19. Treatment, services, and supplies for growth hormone therapy, including growth hormone
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medication and its derivatives or other drugs used to stimulate, promote, or delay growth or to
delay puberty to allow for increased growth.
20. Treatment, services, and supplies related to the following conditions, regardless of underlying
causes: sex transformation, gender dysphoric disorder, gender reassignment, and treatment of
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sexual function, dysfunction or inadequacy, treatment to enhance, restore or improve sexual

energy, performance, or desire.
21. Treatment, services, and supplies related to maternity or pregnancy (except Complications of
Pregnancy).
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22. Treatment for or treatment use of:

a. genetic testing or counseling, genetic services and related procedures for screening
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purposes including, but not limited to, amniocentesis and chronic villi testing;
b. services, drugs or medicines used to treat males or females for an infertility diagnosis
regardless of intended use including, but not limited to artificial insemination, in vitro
fertilization, reversal of reproductive sterilization, any treatment to promote conception;
c. sterilization;
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d. cryopreservation of sperm or eggs;

e. surrogate pregnancy;
f. fetal surgery, treatment or services;
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g. umbilical cord stem cell or other blood component harvest and storage in the absence of
Sickness or Injury;
h. circumcision;
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i. routine well newborn care at birth including nursery care; or

j. elective abortion.
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23. Treatment for behavior modification or behavioral (conduct) problems, learning disabilities,
developmental delays, attention deficit disorders, hyperactivity, educational testing, training or
materials, memory improvement, cognitive enhancement, or training, vocational or work
hardening programs, transitional living, except for Outpatient diabetes self-management training
and education for treatment of a Covered Person with diabetes.
24. Treatment for or through use of:
a. non-medical items, self-care or self-help programs;
b. aroma therapy;
c. meditation or relaxation therapy;
d. naturopathic medicine;
e. treatment of hyperhidrosis (excessive sweating);
f. acupuncture, biofeedback, neurotherapy, electrical stimulation;
g. Inpatient treatment of chronic pain disorders;
h. treatment of spider veins;
i. family or marriage counseling;

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 j. applied behavior therapy treatment for autistic spectrum disorders;
k. smoking deterrence or cessation;
l. snoring or sleep disorders;
m. change in skin coloring or pigmentation; or,
n. stress Management.
25. Services ordered, directed, or performed by a Health Care Practitioner or Chiropractor, or
supplies purchased from a Medical Supply Provider who is a Covered Person, an Immediate
Family Member, employer of a Covered Person, or a person who ordinarily resides with a
Covered Person.
26. Any amount in excess of the lifetime Maximum Benefit or any other Maximum Benefit limitation
for covered scheduled benefits.
27. Treatment that does not meet the definition of a Covered Event in this Policy including, but not
limited to, treatment that is not Medically Necessary.
28. Treatment services and supplies for Experimental or Investigational Services.
29. Treatment incurred outside of the United States.
30. Sickness or Injury caused or aggravated by suicide, attempted suicide, or self-inflicted Sickness
or Injury.
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31. Drugs or medicines obtained from sources outside the United States.
32. Vitamins and/or vitamin combinations even if they are prescribed by a Health Care Practitioner or
recommended by a Chiropractor.
33. Any prescription products, drugs, or medicines in the following categories, whether or not
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prescribed by a Health Care Practitioner or recommended by a Chiropractor:

a. herbal or homeopathic medicines or products;
b. minerals;
c. appetite suppressants;
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d. dietary or nutritional substances or dietary supplements;

e. nutraceuticals;
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f. medical foods; or,

g. Durable Medical Equipment/supplies.
34. Drugs or medicines that have an over-the-counter equivalent or contain the same or
therapeutically equivalent active ingredient(s) as over-the-counter medication, as determined by
Us.
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35. Drugs or medicines administered at or by the rest home, sanitarium, extended care facility,
convalescent care facility, Skilled Nursing Facility, or similar institution, or dispensed at or by a
Hospital, an Emergency Room, a Free-Standing Facility, an Urgent Care Facility, a Health Care
Practitioner’s office or other Inpatient or Outpatient setting for take home by the Covered Person.
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36. Drugs or medicines used to treat, impact or influence: athletic performance, body conditioning,
strengthening, energy, social phobias, slowing the normal processes of aging, daytime
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drowsiness, overactive bladder, dry mouth, excessive salivation, genetic make-up or genetic
predisposition, prevention or treatment of hair loss, excessive hair growth or abnormal hair
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patterns.
37. Unit-dose drugs, drugs or medicines used to treat onychomycosis (nail fungus), botulinum toxin
and its derivatives.
38. Drugs or medicines prescribed for treatment of a condition specifically excluded under this Policy.
39. Drugs, medicines, or supplies that are illegal under federal law, such as marijuana, even if they
are prescribed for medical use in a state.
40. Duplicate prescriptions, replacement of lost, stolen, destroyed, spilled, or damaged prescriptions;
prescription refills in excess of the number specified on the Health Care Practitioner’s Prescription
Order; prescriptions refilled more frequently than the prescribed dosage indicates, prescriptions
refilled after one year from the Health Care Practitioner’s original Prescription Order, any
administration for drug injections or any other drugs or medicines obtained other than through a
Pharmacy.

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 CLAIM PROVISIONS

NOTICE OF CLAIM
Written notice of claim must be given to Us within 90 days after the date of a loss. If that is not possible,
We must be notified as soon as it is reasonably possible to do so.
When We receive written notice of claim, We will send claim forms. If the claim forms are not received
within 15 days after the notice is sent, written proof of claim can be sent to Us without waiting for the
forms.
PROOF OF LOSS
Proof of Loss must be given to us within 90 days after a loss occurs or starts. If it is not possible to give
proof within this time limit, it must be given as soon as reasonably possible. Proof of Loss may not be
given later than one year after the time such proof is otherwise required, except if the individual is legally
unable to provide it.
Proof of loss includes a claim form or other documents satisfactory to Us.
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Proof of loss may also include statements completed by the Member and/or the claimant, the Employer,
and the attending Health Care Practitioner documenting:
• the nature of the loss;
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• the date, or inclusive dates, of loss; and

• the cause of loss.
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On request, We will tell the Member what forms or documents are required.
We may require authorization to obtain:
• medical information;
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• psychiatric information; and

• non-medical information, such as payroll.
We will give the Member a claim form upon request. He or She is responsible for any costs to complete
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the claim form.

We may ask for other proof of loss from Hospitals and Health Care Practitioners. We will pay the
reasonable cost of obtaining these records.
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PAYMENT OF CLAIMS
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We will pay benefits when We receive proof of loss acceptable to Us.

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We will pay the Member. If He or She does not survive to receive payment We will pay:
• the named beneficiary; or
• The Member’s estate.
If benefits are payable to an estate or to a beneficiary who cannot give Us a valid release, We can pay up
to $2,500 to someone related to the Member, by blood or marriage, whom We find is justly entitled to
payment. Such a payment made in good faith will discharge Us to the extent of the amount paid.
The Member may assign proceeds of a claim. Assignment of a Certificate is not allowed.
RIGHT TO RECOVERY
We reserve the right to recover any payments made by Us that were:

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• made in error;
• made to You and/or any party on Your behalf, where We determine that such payment made is
greater than the amount payable under the Policy;
• made to You and/or any party on Your behalf based on fraudulent or misrepresented information; or
• made to You and/or any party on Your behalf for charges that were discounted, waived, or rebated.
We will not request all or a portion of a payment made to a claimant, more than 12 months after the
payment is made or to a health care provider more than 18 months after the payment is made.
The above does not apply if the payment was made due to fraud committed by the claimant or health
care provider or the claimant or health care provider has otherwise agreed to make a refund to the
Company for overpayment of a claim.
RIGHT TO COLLECT NEEDED INFORMATION
You must cooperate with Us and when asked, assist Us by:
• authorizing the release of medical information including the names of all providers from whom You
received medical attention;
• obtaining medical information and/or records from any provider as requested by Us;
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• providing information regarding the circumstances of Your Injury or Sickness; and

• providing information We request to administer the Policy.
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If You fail to cooperate or provide the necessary information, We may recover payments made by Us and
deny any pending or subsequent Claim for which the needed information is requested.
TIME PAYMENT OF CLAIMS
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Payment will be issued immediately when We receive proof of loss acceptable to Us. Subject to due
written proof of loss, any balance remaining unpaid upon the termination of liability will be paid
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immediately upon receipt of due written proof.

PORTABILITY
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Portability allows an eligible Member to keep this Policy's Benefits at certain times when His coverage
would otherwise end. This is subject to the Benefits Condition, Limitations, and Exclusions.
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Coverage is provided under the terms and conditions of this Policy.

WHEN PORTABILITY IS AVAILABLE
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Subject to the Portability Benefit Conditions and Limitations provision, a covered Member may port
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benefits when He or She:

• has been continuously covered by this Policy for at least 6 months;

• is less than Age 70;
• is not Totally Disabled; and
• is no longer Actively at Work as an Member.

This Policy must be in force on the date that the covered Member ports coverage.

HOW TO EXERCISE PORTABILITY

The covered Member must, within 63 days after the date that His or Her coverage would end:
• submit written application on a form approved by Us; and
• pay the first premium for ported coverage.

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EFFECTIVE DATE OF PORTED INSURANCE
When the first premium for ported insurance is paid, coverage will start on the date that coverage under
this Policy would have ended.
PREMIUM AND PREMIUM DUE DATES
The covered Member must pay premiums to Us by monthly bank draft or other mode of premium
payment that We approve.
After insurance is effective, there is a 31-day grace period for each premium due. If the premium due is
not paid, the grace period begins on the day of the month that coverage began. Coverage remains in
effect during the grace period.
The premium rate and premium changes that apply to a class of Members will apply to former class
Members who have ported their coverage.
We may add a billing fee to the class rate applicable to ported Certificates.
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If premiums for a class change, We will provide advance written notice to persons who have ported
coverage according to the situs state regulations.
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AMOUNT OF INSURANCE
Subject to the Changes to Amount of Ported Coverage provision, insurance provided will be that which
was in effect on the day prior to the Effective Date of ported insurance.
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CHANGES TO AMOUNT OF PORTED COVERAGE

Benefits provided under the Portability provision cannot be increase.
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If the Member decreases or ends a ported benefit, any change in premium will take place on the first day
of the calendar month after We receive and approve the request.
When insurance ends for a class, the termination will apply to former members of the class who have
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ported.
TERMINATION OF PORTED INSURANCE
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Ported insurance for the covered Member and any Covered Dependents ends on the earliest of the
following dates:
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• when the Member requests termination;

• at the end of the grace period, if the premium is not paid;
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• when the Member reaches the maximum renewal age;

• a date or Age for termination of insurance for the Covered Person shown on the Schedule;
• for a Spouse or child, when He or She no longer meets the Policy's definition of Covered Dependent;
• for a Spouse, Age 70;
• for a child, age 26;
• on the next premium due date following the Member's dealth;
• when coverage of the class to which the Member belonged prior to porting ends; or
• when this Policy ends.

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PORTABILITY BENEFIT CONDITIONS AND LIMITATIONS
Unless stated, any changes to the Policy apply to ported insurance. A Totally Disabled Member is not
eligible to use this benefit.
A covered Member cannot port while absent from work due to:
• temporary layoff;
• suspension of business operations; or
• Policyholder-approved leave of absence for non-medical reasons.

An Member is not eligible to port coverage while Policy coverage is continued based on a state or federal
law, regulation, or rule.
An Member is not eligible to port coverage when this Policy ends.

TERMINATION OF INSURANCE – COVERED PERSONS

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For all Covered Persons of this Policy, all insurance ends:

1. as of the last premium paid date, subject to the grace period provision;
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2. at the end of the calendar month when We receive a request to end this Policy; or
3. on this Policy’s termination date.

For all Covered Persons of a Certificate, all insurance ends on the earlier of the following:
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1. on this Policy’s termination date; or

2. at the end of the grace period, if premium for this insurance is not paid.
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Insurance will also end at the end of the calendar month when:
1. the Member retires;
2. the Member is no longer eligible for this insurance;
3. the Member reaches Age 71;
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4. We receive a request to end this insurance; or

5. the Member dies.

For Covered Dependents, all insurance under this Policy ends at the end of the calendar month:
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1. if a Spouse, when the Spouse reaches Age 71;

2. if a Child, when the Child reaches Age 26; or
C

3. when He or She is no longer eligible for this insurance.

Y

When the Member’s insurance ends, insurance on all other Covered Persons of the Certificate will also
end.

Ending of the insurance will not prejudice claims that occur or start prior to the date insurance ended.
VOLUNTARY TERMINATION
The Policyholder must notify Us of voluntary terminations. The date insurance ends will be the last day of
the calendar month in which the termination took place. If the Policyholder fails to report voluntary
terminations, Our liability shall be limited to a return of premium back to the last Policy Anniversary, less
any claims paid during this period.

AN7002-OK 13
POLICY RENEWAL, AMENDMENT AND TERMINATION

POLICYHOLDER RENEWAL
With Our consent, the Policyholder may renew this Policy on each Policy Renewal Date. This is subject to
the payment of premiums.
Insurance will end at 11:59 p.m. local time at the Policyholder’s mailing address as shown in Our records
on the day before the Effective Date of the Policy anniversary if it is not renewed, unless it ends as
provided in the Policy Termination provision.
POLICY AMENDMENT
The Policyholder may request changes to the Policy terms to add, modify or delete benefits or other
terms. All requested changes will be reviewed by Us, and an amendment issued upon approval.
On any Policy Renewal Date, We may amend this Policy to add, modify or delete benefits or other terms.
We will give the Policyholder at least 45 days advance written notice of any such change.
SP

Deletion or reduction of a benefit is without prejudice to any claim that took place or started prior to the
date of the change.
A change in or deletion of benefits may change the premiums charged.
EC

POLICY TERMINATION
The Policyholder has the right to cancel this Policy on any premium due date. Written notice must be
IM

given to Us at least 30 days before the date this Policy is to end.

We have the right to cancel this Policy on:
EN

• any Policy Renewal Date; or

• any premium due date.
We will give the Policyholder at least 45 days’ notice before this Policy is to end.
PO

This Policy and its insurance shall end if the Policyholder fails to pay the Premium before the end of the
grace period.
Termination is without prejudice to any claim that takes place or starts prior to the date of termination.
LI
C
Y

PREMIUM PROVISIONS

PREMIUMS
Premiums are payable to the Company.
The first premium is due on the Effective Date of this Policy. Later premiums are due according to the
mode of premium payment shown on the face page of this Policy.
We actuarially determine the premiums. We reserve the right to change the premiums as stated in the
Change in Premium provision.

AN7002-OK 14
CHANGE IN PREMIUM
We may change the premium rates:
• when the number of Members covered changes by 20% or more after the Effective Date of this
Policy, or the last renewal date, if later;
• whenever Policy terms or conditions are modified;
• when there is a material change in the risk insured;
• when the Policyholder is sold or merges with another entity;
• when the Policyholder purchases, acquires or establishes a new affiliate or subsidiary; or
• on any Policy Renewal Date.
We will provide the Policyholder with at least 45 days advance written notice of any Premium rate
change.
GRACE PERIOD
This Policy has a thirty-one (31) day grace period. If any required premium is not paid on or before the
due date, it may be paid subsequently during the grace period. During the grace period, the Policy will
SP

stay in force. If full payment is not received within the grace period, insurance will be terminated effective
the first day of the grace period.
REFUND OF UNEARNED PREMIUM
EC

Within 30 days of proof of an Member’s death, We will refund any unearned premium paid for such
person for any period beyond the end of the month in which death occurred.
IM
EN

GENERAL PROVISIONS

AGREEMENTS AND POLICY CHANGES

PO

No change in this Policy shall be valid unless made by endorsement or amendment. Such a change is
valid only if signed by Our Chairman or Our President. No other person can waive any Policy terms or
make any agreements about this Policy that are binding on Us.
LI

ASSIGNMENT
The Member may assign proceeds of a claim by notifying Us in writing.
C

We are not responsible:

Y

• for the validity of any assignment; or

• to honor any assignment unless it is given to Us with any claim subject to the assignment.

Our payment in good faith as outlined above will fully discharge Us with respect to the amount(s) paid.
Assignment of this Policy or of a Certificate is not allowed.
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 any change of beneficiary or beneficiaries.

AN7002-OK 15
CERTIFICATES
We will deliver a Certificate electronically, unless otherwise required by state law, to the Member stating:
• the insurance protection provided; and
• any insurance for Covered Dependents.

CONFORMITY WITH STATE STATUTES

Any Policy wording in conflict with the statutes of the Situs State is hereby amended to meet the minimum
requirements of such statutes.
DATE OF BIRTH
If a Covered Person’s date of birth is misstated, We will adjust the premiums that we would have charged
based on the correct issue age.
ENTIRE CONTRACT
This Policy, the Certificate, the Application as well as any endorsements and amendments shall make up
SP

the entire contract.

Statements made by the Policyholder or Covered Persons shall be deemed representations and not
warranties.
EC

EXAMINATION AND AUTOPSY

We, at Our own expense, will have the right and opportunity to have a Covered Person examined by a
IM

medical professional of Our choice. We may use this right as often as reasonably required.
INCONTESTABILITY
EN

We will not contest the validity of the Policy except for nonpayment of premiums after it has been in force
for two (2) years from the Effective Date of this Policy.
No statements other than fraudulent misstatements made by any Covered Person shall be used in any
PO

contest unless a copy of the statement is or has been furnished to:

• the Member; or
• in the event of death or incapacity of the Member, to His or Her beneficiary or personal
representative.
LI

Except for claims incurred within two (2) years after a Covered Person’s Effective Date of insurance, no
C

statements other than fraudulent misstatements made by any Covered Person when applying for
insurance will be used to contest the validity of that insurance after:
Y

• the insurance has been continuously in force for two (2) years during the lifetime of the person
insured; and
• unless it is contained in a written form signed by the Covered Person.

This provision shall not stop Us from asserting at any time defenses based upon Policy terms that relate
to eligibility for insurance.
INSURANCE FRAUD
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of
a felony.
If a Covered Person commits fraud against Us, as determined by Us, the Covered Person’s insurance
ends automatically, without notice, as of the date fraud is committed or as of the date otherwise
determined by Us.

AN7002-OK 16
LEGAL ACTIONS
Legal action cannot be taken against ManhattanLife Insurance and Annuity Company:
• sooner than 60 days after due proof of loss has been filed; or
• later than three years after the time written proof of loss is required to be filed according to the terms
of this Policy.

NON-PARTICIPATING
This Policy is a non-participating policy. We will not pay dividends on this Policy.

DEFINITIONS

For the purposes of this Policy and the Certificates, the following words have the meanings stated.
SP

Accident or Accidental: An unforeseen and unplanned event that occurs unintentionally and
unexpectedly, independent of disease, bodily infirmity, or any other cause, resulting in injury to a Covered
Person that is not due to any fault or misconduct on the part of the injured Covered Person.
EC

Actively At Work (Active Employment): The Member must be working:

• on a full-time basis and paid regular earnings;
• at least the minimum number of hours stated in the Eligibility Provision; and
IM

• at the Employer’s usual place of business or at a location to which the Employer’s business requires
the Member to travel.
EN

A Member will be considered Actively At Work if the Member was actually at work on the day immediately
preceding:
• a weekend;
• holidays;
PO

• paid vacations;
• any non-scheduled work day.

An Member classified as part-time or temporary workers by the Employer or Policyholder are not Actively
LI

At Work except as agreed between the Policyholder and the Company.

C

An Member on Strike is not Actively at Work except as agreed between the Policyholder and the
Company.
Y

Age: The age of a Covered Person on His or Her last birthday as of the Effective Date of insurance. Age
increases by one year on each Date of Policy anniversary.
Ambulatory Surgical Center and/or Outpatient Hospital Facility: Any public or private surgical facility:
1. with an organized medical staff of duly licensed physicians;
2. with a permanent facility equipped and operated primarily for the purpose of performing surgical
procedures;
3. with continuous Health Care Practitioner services whenever the patient is in the facility; and,
4. which does not provide services or accommodations for patients to stay overnight.

Application: the forms the Policyholder completed when applying for this Policy that are attached to this
Policy.

AN7002-OK 17
Association means an entity that:
1. has been actively in existence for at least 5 years;
2. has been formed and maintained in good faith for purposes other than obtaining insurance;
3. does not condition its membership in the association on any health status-related factor relating to an
individual (including an employee of an employer or a dependent of any employee);
4. makes insurance coverage it offers available to all members regardless of any health status-related
factor relating to the members (or individuals eligible for coverage through a member);
5. does not make insurance coverage it offers available other than in connection with a member of the
association; and
6. meets any additional requirements that may be imposed under laws of the Situs State.
Calendar Year: The period beginning on the Effective Date of the Policy and ending on December 31 of
the same year. Thereafter, every year beginning on January 1 and ending on the subsequent December
31.
Cancer: An internal disease identified by the presence of malignant cells or a malignant tumor
characterized by the uncontrolled and abnormal growth and spread of invasive malignant cells. This
includes Hodgkin’s Disease, leukemia, lymphoma, carcinoma, sarcoma, or melanoma.
SP

Unless otherwise stated, the following are not to be construed as Cancer for purposes of this Policy:
1. pre-malignant conditions or conditions with malignant potential;
2. basal cell carcinoma and squamous cell carcinoma of the skin; or,
EC

3. melanoma diagnosed as Clark’s Level 1 or 2 (Breslow less than 0.75mm) or melanoma in situ.

Certificate: The document We issue for delivery to each Member stating the protection to which He or
IM

She is entitled, to whom We will pay benefits and the names of each Covered Dependent.

Chiropractor: A person who has a Doctor of Chiropractic (D.C.) degree and who is licensed by the state
EN

or other geographic area in which the chiropractic treatment is rendered, and a claim is made.

Complications of Pregnancy: Complications of Pregnancy include the following:

1. conditions requiring Hospital confinement (when the pregnancy is not terminated) whose diagnoses
PO

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; and
2. non-elective cesarean section, termination of ectopic pregnancy, and spontaneous termination of
LI

pregnancy, which occurs during a period of gestation in which a viable birth is not possible.
3. Complications of pregnancy shall not include false labor, occasional spotting, Health Care
C

Practitioner-prescribed rest during the period of pregnancy, morning sickness, hyperemesis

gravidarum, preeclampsia, and similar conditions associated with the management of a difficult
Y

pregnancy not constituting distinct complication of pregnancy.

Confinement Period: A continuous and uninterrupted period of at least 24 hours during which a Covered
Person is admitted to and discharged from a Hospital to obtain Medically Necessary Inpatient treatment
of a Sickness or Injury while under the regular care and attendance of a Health Care Practitioner. There
must be a charge for room and board.
Cosmetic Service: A surgery, procedure, injection, medication, or treatment primarily designed to
improve appearance, self-esteem, or body image, and/or to relieve or prevent social, emotional, or
psychological distress.
Covered Dependent: A Covered Dependent is:
1. The lawful Spouse of an Member; or,
2. any dependent child(ren) for whom an Member has applied for insurance under the Policy and for
whom premium payments are made. At the time of application, a dependent child must be:
a. dependent upon the Member for his or her support;

AN7002-OK 18
 b. unmarried;
c. under the age of 26; and,
d. The Member’s child or their Spouse’s child, natural born, legally adopted, or pending legal
adoption and is in placement in the residence of the Certificateholder. A dependent child
includes a child under a medical support order.
Coverage of an insured child ends on the premium due date following the attainment of age 26, or
marriage, whichever occurs first. However, coverage may be continued for a physically or mentally
handicapped child who is incapable of self-sustaining employment and is dependent on the Member for
support. Proof of this must be received at least 31 days before such child attains age 26. We reserve the
right to require additional proof of such incapacity and dependency; however, We will not require such
proof more than once a year after the 2-year period the dependent child attains age 26.
Covered Event: A medical event for which this Policy provides a scheduled benefit and meets all of the
following requirements:
1. the treatment, services, or supplies provided in connection with the event are provided by a duly
licensed health care provider, facility, or supplier;
2. it is incurred by a Covered Person while coverage is in force under this Policy and their Certificate as
SP

the result of Sickness or Injury;

3. it is incurred for events shown in the Benefits section and on the Schedule of Benefits; and,
4. the occurrence includes treatment, services, or supplies which are Medically Necessary.
EC

Covered Person: An Eligible Member or Covered Dependent who is covered under this Policy. Persons
eligible for insurance are shown on the Certificate Schedule.
Custodial Care: Care, regardless of setting, primarily for the purpose of meeting the personal needs of
IM

the patient, including but not limited to, assisting in the activities of daily living, providing help in walking or
getting in or out of bed, assisting with bathing, dressing, feeding, homemaking, or preparation of special
diets, supervision of medication, providing companionship, or ensuring safety.
EN

Durable Medical Equipment: Equipment, such as a Hospital bed, wheelchair, or crutches, customarily
used to serve a medical purpose and is designed for and able to withstand repeated use and is intended
for use by successive patients.
PO

Effective Date: The date coverage under this Policy takes effect.

Emergency Room: A place affiliated with and physically connected to a Hospital and used primarily for
LI

short-term Emergency Treatment or a free-standing emergency facility.

C

Emergency Treatment: Bonafide emergency services provided after the sudden onset of a medical
condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the
Y

absence of immediate medical attention could reasonably be expected to result in:

1. placing the Covered Person’s health in serious jeopardy;
2. serious impairment to bodily functions of the Covered Person; or,
3. serious dysfunction of any bodily organ or part of the Covered Person.

Enroll: Application by the Member for Policy coverage. By agreement between Us and the Policyholder,
enrollment may:
1. require completion of an enrollment form by the Member; or,
2. be automatic, in which case it is not necessary for the Member to complete an enrollment form; and
3. require evidence of insurability.

Experimental or Investigational Services: Treatment, services, or supplies which are:

1. not given to be of benefit for diagnosis or treatment of Sickness or Injury;
2. not generally used or recognized by the medical community as safe, effective, and appropriate for
diagnosis or treatment of Sickness or Injury;

AN7002-OK 19
3. in the research or investigational stage, provided or performed in a special setting for research
purposes, or under a controlled environment or clinical protocol; or
4. obsolete or ineffective for the treatment of Sickness or Injury.

Free-Standing Facility: A facility that provides interventional services on an Outpatient basis, which
require hands-on care by a Health Care Practitioner.

This type of facility may also be referred to as;

1. an Ambulatory Surgical Center;
2. an interventional diagnostic testing facility;
3. an independent laboratory;
4. a facility that exclusively performs endoscopic procedures; or,
5. a dialysis unit.

A designated area within a Health Care Practitioner’s office or clinic used exclusively to provide
interventional services is also considered to be a Free-Standing Facility.
SP

These facilities must meet all of the following requirements:

1. be licensed by the state in accordance with the laws for the specific services being provided in that
facility;
2. cannot provide room and board and overnight services; and
EC

3. cannot primarily provide care for Mental or Nervous Disorders and Substance-Related Disorders or
be an Urgent Care Facility.

Health Care Practitioner: A person licensed by the state or other geographic area in which the treatment
IM

or services are rendered to treat the Sickness or Injury for which a claim is made. The Health Care
Practitioner must be practicing within the limits of his or her license and in the geographic area in which
EN

he or she is licensed. The term Health Care Practitioner does not include a Chiropractor, or any Covered
Person or any Covered Person’s Immediate Family Member. Benefits will be paid only if the services
provided are covered under this Policy.

Home Health Care: Treatment, services, or supplies provided as part of a program for care and
PO

treatment in a Covered Person’s home.

Hospice: An organization that provides medical services in an Inpatient, Outpatient, or home setting to
LI

support and care for persons who are terminally ill.

Hospital: A facility that provides acute care for Sickness or Injury on an Inpatient basis. This type of
C

facility must:
1. be licensed as a Hospital and operational pursuant to law;
Y

2. be primarily engaged in providing or operating either on its premises or in facilities available to the
Hospital on a contractual prearranged basis and under the supervision of a staff of one or more duly
licensed physicians, medical, diagnostic, and major surgery facilities for the medical care and
treatment of sick or injured persons on an Inpatient basis for which a charge is made;
3. provide 24-hour nursing service by or under the supervision of a registered graduate professional
nurse (RN);
4. maintain and operate a minimum of five (5) beds;
5. maintain permanent medical records that document all services provided to each patient;
6. provide access to laboratory and imaging services at appropriate in-house facilities or offsite facilities
on a prearranged contractual basis; and
7. not primarily provide care for Mental or Nervous Disorders and Substance-Related Disorders
although these services may be provided in a distinct section of the same physical facility.

A Hospital does not include convalescent, nursing, rest, or extended care facilities or facilities operated
exclusively for treatment of the aged, whether such facilities are operated as a separate institution or as a

AN7002-OK 20
section of an institution operated as a Hospital. A Hospital does not include a facility primarily providing
Custodial Care or educational services.
Immediate Family Member: An Immediate Family Member is:
1. You or Your spouse;
2. the children, brothers, sisters, and parents of either You or Your spouse;
3. the spouses of the children, brothers, and sisters of You and Your spouse; or,
4. anyone with whom a Covered Person has a relationship based on a legal guardianship.
Injury: Physical damage to the structure or function of the body caused by an outside force, which may
be physical or chemical, as a result of an Accident.
Inpatient: Admitted to a Hospital for a Medically Necessary stay for Sickness or Injury. There must be a
charge for room and board.
Laboratory Tests: Testing of bodily fluids or tissues for purposes of determining the cause and severity
of a condition for preventive and screening purposes.
Maximum Benefit: The maximum amount of benefits, as shown on the Schedule of Benefits, that We will
SP

pay for each Covered Person under this Policy. This Policy has varying types of Maximum Benefit
limitations. Each Maximum Benefit limitation is stated on the Schedule of Benefits corresponding to the
applicable benefit provision. This maximum will apply even if coverage with Us is interrupted. When the
EC

lifetime Maximum Benefit has been paid by Us, no further benefits are payable for that Covered Person.
Medical Supply Provider: Agencies, facilities, wholesale, or retail outlets that make disposable medical
products available for use.
IM

Medically Necessary or Medical Necessity: Treatment, services, or supplies prescribed by a Health

Care Practitioner or Chiropractor rendered to diagnose or treat Sickness or Injury as part of a Covered
Event. Medical Necessity does not include care prescribed or provided on the recommendation of a
EN

Covered Person’s Immediate Family Member. We must determine such care:

1. is appropriate and consistent with the diagnosis and does not exceed in scope, duration, intensity that
level of care which is needed to provide safe, adequate, and appropriate diagnosis and treatment of
the Sickness or Injury;
PO

2. is commonly accepted as proper care or treatment of the condition in accordance with United States
medical practice and federal government guidelines; and,
3. is provided in the most conservative manner or in the least intensive setting without adversely
affecting the condition or the quality of medical care provided.
LI

The fact a Health Care Practitioner or Chiropractor may prescribe, order, recommend, or approve a
C

treatment, service, or supply, does not make the treatment, service, or supply Medically Necessary.
Y

Member: A person who is in a Class shown on the Schedule and in good standing as defined by the
Association’s requirements and bylaws.

Mental or Nervous Disorders: Neurosis, psychoneurosis, psychosis, or mental or emotional disease or

disorder of any kind.
Observation Unit: A specified area within a Hospital, apart from the Emergency Room, that provides an
alternative to discharge or Hospital Inpatient admission for the Emergency Room patient who may benefit
from an extended observation period by a Health Care Practitioner.
Occupational Therapy: The treatment of Sickness or Injury, by a Health Care Practitioner who is an
occupational therapist, using purposeful activities or assistive devices that focus on all of the following:
1. developing daily living skills;
2. strengthening and enhancing function;
3. coordination of fine motor skills; and

AN7002-OK 21
4. muscle and sensory stimulation.
Office Visits: An in-person, face-to-face meeting, or consultation between a Covered Person and a
Health Care Practitioner in the Health Care Practitioner’s office or a Retail Health Clinic. During this
meeting, the Health Care Practitioner evaluates and manages the Covered Person’s Sickness or Injury or
provides preventive medicine services. For the purposes of this Policy, an Office Visit does not include
services received in:
1. a Hospital’s Outpatient department;
2. an Emergency Room;
3. a Free-Standing Facility; or
4. an Urgent Care Facility.
Outpatient: Treatments, services and/or supplies rendered on anything other than an Inpatient basis.
Personal Medical Equipment: Equipment customarily used to serve a medical purpose, is designed for
and able to withstand repeated use, and is not intended for use by successive patients.
Pharmacy: A licensed establishment where Prescription Drugs are dispensed by a licensed pharmacist
in accordance with all applicable state and federal laws.
SP

Physical Medicine: Treatment, by a Health Care Practitioner, of physical conditions relating to bone,
muscle, or neuromuscular pathology, including but not limited to, Occupational Therapy, Physical
EC

Therapy, and Speech Therapy. This treatment focuses on restoring function using mechanical or other
physical methods.
Physical Therapy: The treatment of Sickness or Injury, by a Health Care Practitioner who is a physical
IM

therapist, using therapeutic exercise and other services that focus on improving:
1. posture;
2. locomotion;
EN

3. strength;
4. endurance;
5. balance;
6. coordination;
7. joint mobility;
PO

8. flexibility;
9. functional activities of daily living; and,
10. alleviating pain.
LI

Policy: The group Policy issued to the Policyholder.

C

Policy Renewal Date: Each anniversary of the Effective Date of the Policy.
Y

Policyholder: The entity so named on this Policy’s face page.

Prescription Drug: Any medication that:
1. has been fully approved by the Food and Drug Administration (FDA) for marketing in the United
States;
2. can be legally dispensed only with the written Prescription Order of a Health Care Practitioner in
accordance with applicable state and federal laws; and,
3. contains the legend wording: "Caution: Federal Law Prohibits Dispensing Without Prescription" or
"RX Only" on the manufacturer’s label, or similar wording as designated by the FDA.
For any drug or biological product, final approval must have been received by the FDA to market it for the
particular Sickness or Injury. Any approval granted as an interim step in the FDA regulatory process, such
as an investigational new drug exemption, is not sufficient.
Prescription Order: The request by a Health Care Practitioner for:
1. each separate Prescription Drug and each authorized refill;

AN7002-OK 22
2. insulin or insulin derivatives only by prescription; or,
3. any one of the following supplies used in the self-management of diabetes and purchased during the
same transaction only by prescription:
a. disposable insulin syringes and needles; or,
b. disposable blood/urine/glucose/acetone testing agents or lancets.
Pre-existing Condition: A condition and related complications:
1. for which medical advice, diagnosis, care, or treatment was sought, received, or recommended from
a provider or for which Prescription Drugs were prescribed during the 12-month period immediately
prior to the Covered Person’s Effective Date, regardless of whether the condition was diagnosed,
misdiagnosed, or not diagnosed; or,
2. that produced symptoms during the 12-month period immediately prior to the Covered Person’s
Effective Date which reasonably should have caused or would have caused an ordinarily prudent
person to seek diagnosis or treatment.
Radiology Tests: Diagnostic imaging procedures and testing performed to diagnose a condition,
determine the nature of a condition, or provide preventative screening including:
1. x-rays;
SP

2. positron emission tomography (PET) scan;

3. magnetic resonance imaging (MRI); and,
4. computerized axial tomography (CT).
EC

Rehabilitation Unit: Specialized treatment received in a unit for Sickness or Injury that meets all of the
following requirements:
1. has a program of services provided by one or more members of a multidisciplinary team;
IM

2. is designed to improve the patient’s function and independence;

3. is under the direction of a qualified Health Care Practitioner; and,
4. follows a formal written treatment plan with specific attainable and measurable goals and objectives.
EN

Retail Health Clinic: A facility that meets all of the following requirements:
1. is licensed by the state in accordance with the laws for the specific services being provided in that
facility;
2. is staffed by a Health Care Practitioner in accordance with the laws of that state;
PO

3. is attached to or is part of a store or retail facility;

4. is separate from a Hospital, Emergency Room, acute medical rehabilitation facility, Free-Standing
Facility, Skilled Nursing Facility, sub-acute rehabilitation facility, or Urgent Care Facility, and any
Health Care Practitioner’s office located therein even when services are preformed after normal
LI

business hours;
5. provides general medical treatment of services for Sickness or Injury, or provides preventive medical
C

services; and,
Y

6. does not provide room and board or overnight services.

Sickness: A disease or an illness of a Covered Person that first manifested itself after the Covered
Person’s Effective Date and while this Policy is in force. Sickness does not include pregnancy or
Complications of Pregnancy.
Skilled Nursing Facility: A facility that provides continuous skilled nursing services on an Inpatient basis
for persons recovering from Sickness or Injury. The facility may also provide extended care or Custodial
Care.

AN7002-OK 23
Speech Therapy: The treatment of Sickness or Injury, by a Health Care Practitioner who is a speech
therapist, using rehabilitative techniques to improve function for:
1. voice;
2. speech;
3. language; and,
4. swallowing disorders.

Spouse:
1. the person recognized as the covered Member’s husband or wife under the laws of the Member’s
state of residence; or
2. the person recognized by the covered Member’s state of residence as the covered Member’s civil
union partner.

Substance-Related Disorders: Condition of the mind or body in which chemically active agents, such
as, prescription and illicit drugs, alcohol, and/or tobacco are relied upon to the extent the reliance is
psychological, as in substance abuse, or physiological, as in substance dependence or addiction.
SP

Temporomandibular Joint (TMJ) Dysfunction and Craniomandibular Joint (CMJ) Dysfunction:

1. clicking and/or difficulties in opening and closing the mouth;
2. pain or swelling; and,
3. complications including arthritis, dislocation, and bite problems of the jaw.
EC

Urgent Care: Treatment, services or supplies provided for Sickness or Injury that:
1. develops suddenly and unexpectedly outside of a Health Care Practitioner’s normal business hours;
and
IM

2. requires immediate treatment but is not of sufficient severity to be considered Emergency Treatment.
EN

Urgent Care Facility: A licensed public or private non-Hospital facility that provides Urgent Care on an
Outpatient basis. A Health Care Practitioner’s office is not considered to be an Urgent Care Facility even
if services are provided after normal business hours. Room and board and overnight services are not
covered.
PO

Wellness Visit: A visit with a Health Care Practitioner to develop or update a personalized prevention
plan to help prevent diseases based on the Covered Person’s current health and risk factors.
LI

We, Us, Our, The Company: ManhattanLife Insurance and Annuity Company.

You, Your: The Member.

C
Y

AN7002-OK 24
ManhattanLife Insurance and Annuity Company
10777 Northwest Freeway, Houston, TX 77092

Surgical Schedule
ASSISTANT
CPT DESCRIPTION SURGERY SURGEON ANESTHESIA
SKIN
11042 Debride skin/tissue $64.81 $12.96 $16.20
11100 Biopsy, skin lesion $51.30 $10.26 $12.83
12001 Repair superficial sound(s) $46.21 $9.24 $11.55
17000 destruction of premalignant lesion $54.97 $10.99 $13.74
17108 Destruction of skin lesions $553.58 $110.72 $138.40
BREAST
19102 Breast biopsy percut w/image $73.16 $14.63 $18.29
19301 Partial mastectomy $680.28 $136.06 $170.07
19303 Simple mastectomy $1,001.29 $200.26 $250.32
19307 Mastectomy, modified radical $1,248.89 $249.78 $312.22
19342 Delayed breast prosthesis $963.67 $192.73 $240.92
MUSCULOSKELETAL SYSTEM
SP

22554 Neck spine fusion $1,316.54 $263.31 $329.14

22612 Lumbar spine fusion $1,668.82 $333.76 $417.21
23420 Repair shoulder $1,013.82 $202.76 $253.46
23655 Treat shoulder dislocation $418.57 $83.71 $104.64
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25605 Treat fracture radius/ulna $529.96 $105.99 $132.49

26735 Treat finger fracture, each $622.43 $124.49 $155.61
27130 Total hip arthroplasty $1,421.68 $284.34 $355.42
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27447 Total knee arthroplasty $1,420.25 $284.05 $355.06

28485 Treat metatarsal fracture $567.99 $113.60 $142.00
29806 Shoulder arthroscopy/surgery $1,110.54 $222.11 $277.64
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29827 Arthroscopy rotator cuff repair $1,104.02 $220.80 $276.01

29848 Wrist endoscopy/surgery $535.56 $107.11 $133.89
29881 Knee arthroscopy/surgery $566.61 $113.32 $141.65
RESPIRATORY SYSTEM
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30520 Repair of nasal septum $634.29 $126.86 $158.57

31240 Nasal/sinus endoscopy, surgical $165.14 $33.03 $41.29
31255 Removal of ethmoid sinus $337.86 $67.57 $84.47
31624 Diagnostic bronchoscope/lavage $142.58 $28.52 $35.65
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32655 Thoracoscopy, surgical $998.68 $199.74 $249.67

CARDIOVASCULAR
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33208 Insertion of heart pacemaker $548.36 $109.67 $137.09

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33249 Insertion of pacing defibrillator $965.11 $193.02 $241.28

33533 Coronary artery bypass, arterial single $1,958.61 $391.72 $489.65
35301 Rechanneling of artery $1,193.86 $238.77 $298.47
36556 Insertion non-tunnel centri venous cath $102.69 $20.54 $25.67
36558 Insertion tunneled centri venous cath $275.83 $55.17 $68.96
36620 Insertion catheter, artery $46.34 $9.27 $11.59
92928 Insertion intracoronary stent (PTCA) $623.33 $124.67 $155.83
93452 Left heart catheterization $856.12 $171.22 $214.03

AN7002SS Page 2
ManhattanLife Insurance and Annuity Company
10777 Northwest Freeway, Houston, TX 77092

ASSISTANT
CPT DESCRIPTION SURGERY SURGEON ANESTHESIA
HEMIC/LYMPHATIC SYSTEM
38221 Bone marrow biopsy $71.71 $14.34 $17.93
38230 Bone marrow collection $217.26 $43.45 $54.32
38300 Dainage of lymph node abscess $211.52 $42.30 $52.88
38510 Biopsy/removal, lymph nodes $437.39 $87.48 $109.35
38745 Remove armpit lymph nodes $918.62 $183.72 $229.66
DIGESTIVE SYSTEM
43239 Upper GI endoscopy, biopsy $147.75 $29.55 $36.94
43830 Place gastrostomy tube $733.72 $146.74 $183.43
44005 Freeing of bowel adhesion $1,149.66 $229.93 $287.42
44145 Partial removal of colon $1,741.88 $348.38 $435.47
44970 Laparoscopy, appendectomy $630.58 $126.12 $157.65
45114 Partial removal of rectum $1,909.29 $381.86 $477.32
45378 Diagnostic colonoscopy $197.84 $39.57 $49.46
45380 Colonoscopy and biopsy $215.02 $43.00 $53.76
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45385 Lesion removal colonoscopy $272.16 $54.43 $68.04

47562 Laparoscopic cholecystectomy $689.97 $137.99 $172.49
49568 Hernia repair with mesh $281.02 $56.20 $70.26
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URINARY SYSTEM
50590 Lithotripsy, fragmenting of kidney stone $599.89 $119.98 $149.97
52000 Cystoscopy $86.68 $17.34 $21.67
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52353 Cystouretero with lithotripsy $414.51 $82.90 $103.63

GENITAL SYSTEM
55700 Biopsy of prostate $138.06 $27.61 $34.52
EN

57260 Repair of vagina $785.77 $157.15 $196.44

57288 Repair bladder defect $742.89 $148.58 $185.72
57454 Biopsy/crett of cervix with scope $139.83 $27.97 $34.96
58100 Biopsy of uterus lining $90.27 $18.05 $22.57
PO

58150 Total hysterectomy $1,052.35 $210.47 $263.09

58262 Vaginal hysterectomy inc tubes/ovaries $945.55 $189.11 $236.39
58353 Endometrial ablation, thermal $224.64 $44.93 $56.16
59410 Vaginal delivery $1,084.18 $216.84 $271.05
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59510 Cesarean delivery $2,406.91 $481.38 $601.73

NERVOUS SYSTEM
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61518 Removal of brain lesion $2,896.70 $579.34 $724.18

Y

61548 Removal of pituitary gland $1,653.36 $330.67 $413.34

62270 Spinal fluid tap, diagnostic $81.85 $16.37 $20.46
63020 Neck spine disk surgery $1,217.36 $243.47 $304.34
64721 Carpal tunnel surgery $445.74 $89.15 $111.44
EYE/AUDITORY SYSTEM
65220 Remove foreign body from eye $44.07 $8.81 $11.02
66821 After cataract laser surgery $323.45 $64.69 $80.86
66984 Cataract surgery w/intraocular lens, 1 stage $664.96 $132.99 $166.24
67113 Repair retinal detachment, complex $1,393.05 $278.61 $348.26

AN7002SS Page 2
 NOTICE OF
PROTECTION PROVIDED BY
OKLAHOMA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION

This notice provides a brief summary of the Oklahoma Life and Health Insurance Guaranty
Association (“the Association”) and the protection it provides for policyholders. This safety net was
created under Oklahoma law, which determines who and what is covered and the amounts of
coverage. The Association was established to provide protection in the unlikely event that your life,
annuity or health insurance company becomes financially unable to meet its obligations and is taken
over by its Insurance Department. If this should happen, the Association will typically arrange to
continue coverage and pay claims, in accordance with Oklahoma law, with funding from
assessments paid by other insurance companies.

The basic protections provided by the Association are:

• Life Insurance
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• $300,000 in death benefits

• $100,000 in cash surrender or withdrawal values
• Health Insurance
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• $500,000 in hospital, medical and surgical insurance benefits

• $300,000 in disability income insurance benefits
• $300,000 in long-term care insurance benefits
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• $100,000 in other types of health insurance benefits

• Annuities
• $300,000 in withdrawal and cash values
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The maximum amount of protection for each individual, regardless of the number of policies or
contracts, is $300,000, except that with regard to hospital, medical and surgical insurance benefits,
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the maximum amount that will be paid is $500,000.

Note: Certain policies and contracts may not be covered or fully covered. For example,
coverage does not extend to any portion(s) of a policy or contract that the insurer does not
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guarantee, such as certain investment additions to the account value of a variable life insurance
policy or a variable annuity contract. There are also various residency requirements and other
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limitations under Oklahoma law.

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To learn more about the above protections, please visit the Association’s website at
www.oklifega.org, or contact:

Oklahoma Life & Health Insurance Guaranty Association Oklahoma Department of Insurance
201 Robert S. Kerr, Suite 600 3625 NW 56th Street, Suite 100
Oklahoma City, OK 73102 Oklahoma City, OK 73112
Phone: (405) 272-9221 1-800-522-0071 or (405) 521-2828

Insurance companies and agents are not allowed by Oklahoma law to use the existence of
the Association or its coverage to encourage you to purchase any form of insurance. When
selecting an insurance company, you should not rely on Association coverage. If there is any
inconsistency between this notice and Oklahoma law, then Oklahoma law will control.

OK-GAA (Rev. 11/10) (0311)

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OK-GAA (Rev. 11/10) (0311)