Disclosure

SLPC 28072 1/17 (exp. 1/19)

Gap insurance

What are the exclusions?*

The policy does not provide any benefits for the following: Declared or undeclared war or any act thereof; Suicide or intentionally self-inflicted injury or any attempt thereat, while sane or insane (while sane in CO and MO); Any Hospital Confinement or other covered treatment for Injury or Sickness while an Insured Person is in the service of the armed forces of any country. Orders to active military service for training purposes of two months or less do not, for this exclusion, constitute service in the armed forces of any country. Upon notification to the Company of entering the armed forces of any country, the Company will return to the Insured pro rata premium paid, less any benefits which have been paid, for any period during which the Insured Person is in such service; Confinement in a Hospital or other covered treatment provided in a facility operated by an agency of the United States government or one of its agencies, unless the Insured Person is legally required to pay for the services; Confinement or other covered treatment for Injury or Sickness which is not Medically Necessary; Confinement or other covered treatment for Dental or Vision not related to an accidental injury; Mental or nervous disorders; Alcoholism, drug addiction or complications thereof; Any Hospital Confinement or other covered treatment for Injury or Sickness for which compensation is payable under any Workers’ Compensation Law, any Occupational Disease Law, the 4800 Time Benefit Plan or similar legislation; Any hospital confinement or other covered treatment for Injury or Sickness that is payable under any insurance that does not require Deductible and/or Coinsurance payments by the Insured Person; Any hospital confinement or other covered treatment for Injury or Sickness for which benefits are not payable under the Insured Person’s Major Medical/ Comprehensive Policy; Any hospital confinement or other covered treatment for Injury or Sickness if, on the Insured Person’s effective date of coverage, the Insured Person was not covered by a Major Medical/ Comprehensive Policy. Our sole obligation will then be to refund all premiums paid for that Insured Person; and An Insured Person engaging in any act or occupation which is a violation of the law of the jurisdiction where the loss or cause occurred. A violation of the law includes both misdemeanor and felony violations.

Coverage will continue as long as the group policy remains in force, the premiums are paid and the insured remains eligible for coverage under the policy.

What are the limitations?*

This product does not have a pre-existing condition limitation, however, a condition must be covered under the insured’s major medical or comprehensive medical plan in order for benefits to be payable under this plan. Therefore any pre-existing condition limitation applied to the major medical or comprehensive medical plan, would, in effect, limit coverage under this plan. Pregnancy is covered the same as any other illness for insured employees and their insured spouses, but pregnancy (except for complications of pregnancy) is not covered for dependent children, unless required by state.

*Subject to state law variations.