(Insurer's name and address) IMPORTANT INFORMATION ABOUT THE COVERAGE YOU ARE BEING OFFERED |
Save this statement! It may be important to you in the future. The Washington State Insurance Commissioner requires that we give you the following information about fixed payment benefits.
This coverage is not comprehensive health care insurance and will not cover the cost of most hospital and other medical services. |
This disclosure provides a very brief description of the important features of the coverage being considered. It is not an insurance contract and only the actual policy provisions will control. The policy itself will include in detail the rights and obligations of both the master policyholder and (insurer's name).
This coverage is designed to pay you a fixed dollar amount regardless of the amount that the provider charges. Payments are not based on a percentage of the provider's charge and are paid in addition to any other health plan coverage you may have.
CAUTION: If you are also covered under a High Deductible Health Plan (HDHP) and are contributing to a Health Savings Account (HSA), you should check with your tax advisor or benefit advisor prior to purchasing this coverage to be sure that you will continue to be eligible to contribute to the HSA if this coverage is purchased. |
The benefits under this policy are summarized below.
Type of coverage:
Benefit amount:
Benefit trigger (identify any periods of no coverage such as eligibility or waiting periods):
Duration of coverage:
Renewability of coverage:
Policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described above include the following:
(List all exclusions including those that relate to limitations for preexisting conditions.)
Wash. Admin. Code § 284-96-550
Statutory Authority: RCW 48.02.060, 48.20.550, and 48.21.370. 07-21-073 (Matter No. R 2007-05), § 284-96-550, filed 10/15/07, effective 11/15/07.