UNUM Voluntary Critical Illness Benefit

 

Important note: The information here describes the UNUM voluntary critical illness plan. This voluntary plan was frozen effective December 31, 2020. As a result, it is no longer accepting new enrollments. If you were enrolled in the plan on December 31, 2020, your coverage will continue through payroll deduction until you cancel your coverage. To cancel your coverage, call UNUM directly at 800-635-5597. Basic Company-paid critical illness insurance coverage is provided by the Voya critical illness plan.

 

 

The critical illness plan pays a benefit if you are diagnosed with a critical illness, such as, but not limited to, heart attack, stroke, and cancer. The critical illness benefit is separate from and in addition to your medical coverage. You are eligible if you are covered by a Company medical plan or other group medical plan.

The plan also includes a mammography benefit that pays you money for receiving mammograms.

The plan is administered by Unum.

This information here is intended to help you understand the plan and how it works. It is not the official Summary Plan Description. To view the complete Summary Plan Description, please reference the Voluntary Carrier Booklet, and CMSU Wrap SPD.

  

Voluntary critical illness benefit highlights

• You may purchase up to $45,000 for yourself and $30,000 for your spouse/domestic partner. Voluntary coverage is paid on an after-tax basis through convenient payroll deductions.
• Eligible children are always covered at 25% of your basic and voluntary amount.
• Use the money any way you choose—pay your medical plan deductible or coinsurance, cover your mortgage, or take a vacation.
• You don't have to be disabled or terminally ill to receive the benefit.

  

Mammography benefit

The plan pays $200 to employees and spouses/domestic partners for receiving a mammogram based on the recommended age guidelines.

 

 

  

  

Critical Illness Benefit Summary

Critical Illness Benefits

• Employees—you may purchase up to $45,000 of coverage in $1,000 increments ($50,000 maximum of basic and voluntary coverage)
• Eligible children—eligible children are automatically covered at 25% of your benefit at no cost to you
• Spouse/domestic partners—if you purchase coverage for yourself, you also have the option to buy voluntary coverage for your spouse/domestic partner of up to $30,000 in $1,000 increments 

No benefits will be paid within the first 30 days of coverage unless for an injury or a listed childhood covered benefit.

CRITICAL ILLNESS CONDITIONS	PERCENT OF BENEFIT ELIGIBLE
Base Covered Conditions (Adults and Children)
Benign Brain Tumor	100%
Blindness	100%
Coma as the Result of Severe Traumatic Brain Injury	100%
Coronary Artery Bypass Surgery	25%
End Stage Renal (Kidney) Failure	100%
Heart Attack (Myocardial Infarction)	100%
Major Organ Failure	100%
Occupational HIV (note: state variations apply—  not covered in CA, IN, and MN)	100%
Permanent Paralysis as the result of a covered accident (note: state variations apply - not covered in PA)	100%
Stroke	100%
Cancer	100%
Carcinoma in Situ	25%
Additional Critical Illnesses for Dependent Children
Cerebral Palsy	100%
Cleft Lip or Palate	100%
Cystic Fibrosis	100%
Down Syndrome	100%
Spina Bifida	100%
Critical illness benefit reduction: On the January 1 following the covered person's 70th birthday, critical illness benefits will reduce to 50% of the original amount.

  

Mammagraphy Benefit

In addition to providing critical illness benefits, the plan also pays you for receiving mammograms.

• Benefit amount. The plan pays $200 for receiving a mammogram based on the recommended age guidelines below.
• Who's eligible. Canon Medical Systems employees and their spouse/domestic partner.
• Waiting period to receive benefit. 30 days.
• How often. The benefit is payable:
  • Once between the ages of 35 to 39;
  • Once every two years between the ages of 40 to 49, or more frequently based on the insured person's physician recommendation; and
  • Once every year while at age 50 and older.

 

  

How the Plan Works

Eligibility and Enrollment

You are eligible for critical illness and mammography benefits if you are covered by a Company-sponsored medical plan or other group medical plan.

This plan is closed to new enrollments. If you were enrolled in the plan on December 31, 2020, your coverage will continue through payroll deduction until you cancel your coverage. To cancel your coverage, call UNUM directly at 800-635-5597.

  

Payment of Benefits

All benefits will be paid in a lump sum to you. If a dependent child is insured by two employees and makes a claim, you choose whose benefits to use. Unum will only pay benefits under one parent's coverage.

Unum will pay benefits for the critical illnesses listed under What's Covered if:

• The date of diagnosis is at least 30 days after your coverage is in force (this 30-day period is the plan's benefit waiting period)
• The benefit claim is medically unrelated to any previously paid critical illness benefit for the same person
• It has been 90 days or more since the last claim
• Benefits would not otherwise be denied due to plan limitations or exclusions, or failure to meet conditions as required by Unum

  

Taxation of Benefits

Voluntary critical illness and wellness benefits are not taxable to you.

  

Pre-Existing Conditions

Unum will not pay benefits for a claim that is caused by, contributed to by or occurs as a result of a pre-existing condition or any medical or surgical treatment for that condition for which the date of diagnosis is in the first 12 months after your coverage effective date. However, pre-existing conditions are covered if diagnosis occurs after the insured person has been covered by the plan for 12 months.

For purposes of this plan, a pre-existing condition is defined as a sickness or injury, or symptoms of a sickness or injury, whether diagnosed or not, for which a person received any of the following during the 12 months just prior to his or her coverage effective date:

• Medical treatment
• Consultation
• Care or services, including diagnostic measures
• A prescription for medicine

A pre-existing condition can also be a sickness or injury, or symptoms of a sickness or injury, whether diagnosed or not, for which an ordinarily prudent person would have consulted a health care provider during the 12 months just prior to the his or her coverage effective date.

The pre-existing condition will apply to any new or increased coverage.

The pre-existing condition limitation does not apply for dependent children who are born or adopted while you are covered under this policy, and who are continuously covered from the date of birth or adoption.

  

Making Changes

You can change coverage for you or your spouse/domestic partner during the annual enrollment period. Evidence of Insurability is required for any additional coverage. Additional coverage will begin at 12:01 a.m. on the later of:

• The first day of the month following the end of the annual enrollment period; or
• The first of the month following the date Unum approves your proof of good health.

Any additional coverage will be subject to a new pre-existing condition limitation and a new benefit waiting period.

A decrease in coverage will begin at 12:01 a.m. on the first of the month following the date you provide notification to the Benefits Department.

Coverage changes will not affect a claim that occurs before the effective date of the change.

If you are absent from work on the date your change in coverage would normally begin due to injury or sickness any coverage changes will begin on the date you return to active employment.

Any changes to your coverage will affect your dependent children's coverage.

  

When Coverage Ends

For You

If you choose to cancel your coverage under the policy, your coverage ends on the first of the month following the date you provide notification to the Benefits Department.

Otherwise, your coverage ends on the earliest of the:

• Date this policy is cancelled
• Date you are no longer in an eligible group
• Date your eligible group is no longer covered
• Date of your death;—last day of the period for which You made any required contributions
• Last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness

Coverage on your dependent children ends on the earliest of the date your coverage under the policy ends or the date a dependent child no longer meets the definition of dependent children.

Unum will provide coverage for a payable claim which occurs while you are covered under this plan.

  

For Your Spouse/Domestic Partner

If you choose to cancel coverage for your spouse/domestic partner under the policy, coverage ends on the first of the month following the date you provide notification to your employer.

Otherwise, spouse coverage under the policy ends on the earliest of the:

• Date this policy is cancelled
• Date you no longer are in an eligible group
• Date your eligible group is no longer covered
• Date of your death
• Last day of the period for which you made any required contributions
• Last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness
• Date your coverage under the policy ends
• Date your spouse no longer meets the definition of spouse
• Date of divorce or annulment.

Unum will provide coverage for a payable claim which occurs while your spouse is covered under the policy.

  

Portability Benefit

For You

If your employment with the Company ends or you are no longer in an eligible group, you may have the right to apply to continue coverage under the policy for yourself, your spouse if covered, and your eligible children. You must apply for coverage under this portability provision and pay the first premium within 31 days after your employment ends or you are no longer eligible.

You can't apply for continuing coverage if the policy is already cancelled or closed to new enrollments or if it is changed to exclude the group of employees to which you belong.

Your continuing coverage will be the same as when you were employed or eligible for coverage. Future changes to the policy will not apply to you. Even if Unum cancels this coverage or closes it for new enrollments, your policy will remain in effect, except as follows:

• You may decrease, but not increase, the amount of your critical illness coverage
• Premiums will be billed directly to you
• Initial premium rates will be based on the portability rates in effect at the time you apply to continue your coverage
• Unum can change premium rates at any time upon 31 days notice to you, so long as the change is not due to any change in your age or health or the age or health of your spouse or your eligible children.

Your continuing coverage will end on the earlier of the following:

• You don't pay the required premium within the 31 day grace period
• The date you die, unless your spouse applies for continuing coverage
• Unum cancels this benefit for any reason upon 31 days notice

Once continuing coverage is cancelled, it cannot be reinstated.

  

For Your Spouse/Domestic Partner 

If you die, divorce, or terminate your domestic partnership, your spouse/domestic partner may have the right to continue family coverage, including eligible dependent children, under this policy. Your spouse/domestic partner must apply for continuing coverage and pay the first premium within 31 days after the date of your death, divorce, or termination of domestic partnership.

If you die and your spouse/domestic partner applies to continue coverage, any eligible dependent children also will be covered. Critical illness coverage for eligible children will be provided at 25% of your spouse/domestic partner's critical illness face amount.

Continued coverage is not available if your spouse/domestic partner was not insured under this policy on the date of your death or divorce.

Coverage for your spouse/domestic partner will be the same as when he or she was an eligible participant. Future changes to the policy will not apply. Even if Unum cancels this coverage or closes it for new enrollments, the policy will remain in effect, except as follows:

• Your spouse/domestic partner may decrease, but not increase, the amount of critical illness coverage,
• Premiums will be billed directly to your spouse/domestic partner
• Initial premium rates will be based on the portability rates in effect at the time continued coverage is requested
• Unum can change premium rates at any time upon 31 days notice, so long as the change is not due to any change in age or health.

Continued coverage for your spouse/domestic partner and children will end on the earlier of the following:

• Your spouse/domestic partner doesn't pay the required premium within the 31 day grace period
• The date your spouse/domestic partner dies, unless your spouse applies for continuing coverage
• Unum cancels this benefit for any reason upon 31 days notice

Once continuing coverage is cancelled, it cannot be reinstated.

  

What's Covered

Certain critical illnesses apply to eligible children only as noted.

  

Benign Brain Tumor

A non-cancerous brain tumor confirmed by the examination of tissue (biopsy or surgical excision) or specific neuroradiological examination. The tumor must result in persistent neurological deficits including but not limited to:

• Loss of vision
• Loss of hearing
• Balance disruption

The date of diagnosis for a benign brain tumor is determined by examination of tissue (biopsy or surgical excision) or specific neuroradiological examination.

Exclusions: For the purposes of this policy, the following are not considered benign brain tumors:

• Tumors of the skull
• Pituitary adenomas
• Germanomas

Unum will not pay for benign brain tumors for individuals diagnosed with any of the following conditions prior to your coverage effective date:

• Neurofibromatosis I
• Neurofibromatosis II
• Von Hippel Lindau
• Tuberous Sclerosis
• Li Fraumani Syndrome
• Cowden Disease
• Turcot Syndrome

  

Blindness

Clinically proven irreversible reduction of sight in both eyes certified by an ophthalmologist with:

• Sight in the better eye reduced to a best corrected visual acuity of less than 6/60 (Metric Acuity) or 20/200 (Snellen or E-Chart Acuity)
• Visual field restriction to 20° or less in both eyes

The date of diagnosis for blindness is the date the ophthalmologist makes an accurate certification of blindness.

  

Cancer

Malignant cells or a malignant tumor characterized by the uncontrolled and abnormal growth and spread of invasive malignant cells.

The date of diagnosis for cancer or carcinoma in situ is the date the tissue specimen, blood samples and/or titer(s) are taken on which the diagnosis is based.

For purposes of this policy, the following are not considered as cancer:

• Pre-malignant conditions or conditions with malignant potential
• Carcinoma in situ
• Basal cell carcinoma and squamous cell carcinoma of the skin, unless metastatic disease develops
• Melanoma that is diagnosed as Clark's Level I or II or Breslow less than .75 mm or melanoma in situ

  

Carcinoma in Situ

A malignant tumor that has not yet become invasive but is confined only to the superficial layer of cells from which it arose (i.e. malignant cells confined to the epithelium without penetration of the basement membrane).

The date of diagnosis for cancer or carcinoma in situ is the date the tissue specimen, blood samples and/or titer(s) are taken on which the diagnosis is based.

For the purposes of this policy, the following are not considered as carcinoma in situ:

• Pre-malignant conditions or conditions with malignant potential
• Basal cell carcinoma and squamous cell carcinoma of the skin
• Melanoma or melanoma in situ

Note: The pathological diagnosis of cancer or carcinoma in situ is based on a microscopic study of fixed tissue or preparations from the hemic (blood) system. A clinical diagnosis of cancer or carcinoma in situ is based on the study of symptoms. Unum pays benefits for a clinical diagnosis only if there is medical evidence to support a positive diagnosis of cancer or carcinoma in situ. Either diagnosis must be done by a qualified physician whose positive diagnosis of malignancy is in keeping with the professional medical standards of care for cancer or carcinoma in situ.

  

Cerebral Palsy (Children Only)

A group of disorders of the development of movement and posture causing activity limitation, that are attributed to progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, cognition, communication, perception, and/or behavior and/or by a seizure disorder.

The date of diagnosis of cerebral palsy is the date a licensed pediatrician or neurologist diagnoses cerebral palsy after live birth.

  

Cleft Lip or Palate (Children Only)

A cleft lip appears as a narrow opening or gap in the skin of the upper lip that extends all the way to the base of the nose. A cleft palate is an opening between the roof of the mouth and the nasal cavity. This policy covers clefts occurring on one side of the mouth (unilateral clefting) or on both sides of the mouth (bilateral clefting).

The date of diagnosis of cleft lip or palate (unilateral or bilateral clefting) is the date given by a physician after a live birth.

  

Coma as the Result of Severe Traumatic Brain Injury

A coma resulting from a severe traumatic brain Injury that results in a continuous state of profound unconsciousness lasting for a period of 14 or more consecutive days, characterized by the absence of:

• Eye opening
• Verbal response
• Motor response

The condition must require intubation for respiratory assistance.

The date of diagnosis is the date a physician confirms the coma as lasting 14 or more consecutive days.

  

Coronary Artery Bypass Surgery

Heart disease or angina that has been clinically diagnosed and requires the insured to undergo coronary artery bypass surgery, which is a surgical procedure to bypass a narrowing or blockage of one or more coronary arteries utilizing venous or arterial grafts.

The date of diagnosis is the date the coronary artery bypass surgery occurs.

For purposes of this policy, the following are not considered as coronary artery bypass surgery:

• Percutaneous coronary intervention (balloon angioplasty),
• Stent implantation, or
• Related procedures to increase the flow of blood through the coronary arteries).

  

Cystic Fibrosis (Children Only)

A diagnosis of cystic fibrosis by a licensed pediatrician or pulmonologist where the dependent child has chronic lung disease and pancreatic insufficiency. The diagnosis of cystic fibrosis made via a sweat test should be based upon sweat chloride concentrations greater than 60 mmol/L.

The date of diagnosis is the date a physician performs this sweat test.

  

Down Syndrome (Children Only)

Down Syndrome is diagnosed through study of the 21st chromosome.  Down Syndrome includes:

• Trisomy 21—An individual has three instead of two number 21 chromosomes.
• Translocation—An extra part of the 21st chromosome is attached to another chromosome.
• Mosaicism—The individual has an extra 21st chromosome in only some of the cells but not all of them. The other cells have the usual pair of 21st chromosomes.

Diagnosis must be confirmed by a licensed pediatrician or another physician familiar with Down Syndrome diagnosis.

  

End Stage Renal (Kidney) Failure  

Chronic irreversible failure of the function of both kidneys such that regular hemodialysis or peritoneal dialysis is required to sustain life.

The date of diagnosis is the date the physician recommends the insured begin renal dialysis.

  

Heart Attack (Myocardial Infarction)

An identifiable clinical event consistent with a heart attack that results in some permanent functional loss of heart contraction detectable by a regional contraction abnormality study on an imaging study and which is defined as having two of the following:

• Typical chest pain
• Electrocardiographic (EKG) changes indicative of Myocardial Infarction; in the case of Myocardial Infarction associated with percutaneous coronary intervention (balloon angioplasty, stent implantation, and related procedures to increase the flow of blood through the coronary arteries), evolving ST elevations or new Q wave changes must be documented and included as one of the criteria on establishing a diagnosis
• Elevation of biochemical markers of myocardial necrosis

The date of diagnosis is the date that the ischemic death of a portion of the heart muscle occurred, based on the criteria listed above.

In the event of death, an autopsy confirmation and/or death certificate identifying myocardial infarction as the cause of death will be accepted.

  

Major Organ Failure

Major organ failure of the liver, both lungs, pancreas, or heart resulting in being placed on the UNOS (United Network for Organ Sharing) list for a transplant. If an insured is on the UNOS list for a combined transplant (example: heart and lung); a single benefit will be paid.

The date of diagnosis is the date that the insured is placed on the UNOS list for transplantation.

Only one Major Organ Failure benefit will be paid per insured.

  

Occupational HIV

Occupational HIV is if an insured contracts HIV as a result of performing the duties of his or her job. The date of diagnosis for Occupational HIV must be after the insured's coverage effective date.

  

Permanent Paralysis as the Result of a Covered Accident

The complete and permanent loss of the use of two or more limbs through paralysis for a continuous period of 90 days as confirmed by a physician.

The date of diagnosis is the date a covered accident occurred which caused the permanent paralysis.

In the case of a transected spinal cord with supporting clinical and radiological evidence and no expectation of return of function, the continuous 90 days requirement specified above is waived.

  

Spina Bifida (Children Only)

A confirmed diagnosis of either of the following types of Spina Bifida:

• Meningocele—The meninges (protective covering of the spinal cord) come through the open part of the spine like a sac that is pushed out. Cerebrospinal fluid is in the sac and there is usually no nerve damage. Individuals may suffer minor disabilities. New problems can develop later in life.
• Myelomeningocele—The meninges (protective covering of the spinal cord) and spinal nerves come through the open part of the spine. This is the most serious type of Spina Bifida, which causes nerve damage and more severe disabilities.

Diagnosis must be made by a licensed physician familiar with Spina Bifida. The date of diagnosis of Meningocele or Myelomeningocele Spina Bifida is determined by a physician familiar with the diagnosis and/or treatment of Spina Bifida after live birth.

Exclusions: This policy excludes Spina Bifida Occulta.

  

Stroke 

A cerebrovascular incident including infarction of brain tissue, cerebral and subarachnoid hemorrhage, cerebral embolism, and cerebral thrombosis. The diagnosis must be supported by:

• Evidence of persistent neurological deficits confirmed by a neurologist at least 30 days after the event
• Confirmatory neuroimaging studies consistent with the diagnosis of a new stroke

The date of diagnosis is the date a stroke occurred based on neuroimaging consistent with an acute or subacute abnormality or other neurodiagnostic study and presence of neurological deficits persisting for a period of 30 days or greater.

For purposes of this policy, the following are not considered as stroke:

• Transient ischemic attack
• Brain injury related to trauma or infection
• Brain injury associated with hypoxia, anoxia, or hypotension
• Vascular disease affecting the eye or optic nerve
• Ischemic disorders of the vestibular system

In the event of death, an autopsy confirmation and/or death certificate identifying stroke as the cause of death will be accepted.

  

What's Not Covered

Unum will not pay benefits for a claim that is caused by, contributed to by or occurs as a result of:

• Participating or attempting to participate in a felony or
  being engaged in an illegal occupation
• Committing or trying to commit suicide or injuring oneself intentionally, whether sane or not
• Participating in war or any act of war, whether declared or undeclared
• Being under the influence of or addicted to intoxicants or narcotics—this would not include physician prescribed medication, taken in the prescribed dosage
• Having a date of diagnosis during the benefit waiting period

  

Pre-Existing Condition Limitation

Unum will not pay benefits for a claim that is caused by, contributed to by or occurs as a result of a pre-existing condition or any medical or surgical treatment for that condition for which the date of diagnosis is in the first 12 months after your coverage effective date. However, pre-existing conditions are covered if diagnosis occurs after the insured person has been covered by the plan for 12 months.

For purposes of this plan, a pre-existing condition is defined as a sickness or injury, or symptoms of a sickness or injury, whether diagnosed or not, for which a person received any of the following during the 12 months just prior to his or her coverage effective date:

• Medical treatment
• Consultation
• Care or services, including diagnostic measures
• A prescription for medicine

A pre-existing condition can also be a sickness or injury, or symptoms of a sickness or injury, whether diagnosed or not, for which an ordinarily prudent person would have consulted a health care provider during the 12 months just prior to the his or her coverage effective date.

The pre-existing condition will apply to any new or increased coverage.

The pre-existing condition limitation does not apply for dependent children who are born or adopted while you are covered under this policy, and who are continuously covered from the date of birth or adoption.

  

Filing Claims 

To obtain a claim form, notify Unum within 90 days of receiving a critical illness diagnosis. If it is not reasonably possible to notify Unum within this period, it must be done no later than one year after notice is required.

Proof of claim must include documentation furnished by a physician and supported by clinical, radiological, histological, pathological, and/or laboratory evidence. It may also include the hospital or physician's bill or other proof of charges. Unum may require you or your dependents to be examined by a physician of their choice at their expense. If you do not obtain the exam or provide information Unum requests to complete your claim, benefits may be denied.

Unum has the right to recover any overpayments due to fraud or errors made when processing the claim.

Send claims to Unum Life Insurance Company at the address shown on the claim form.

  

Appeal Procedures

You have 180 days from the date you receive notice of a denied claim to file an appeal for that claim. Send your written appeal to the address specified in the claim denial. A decision will be made within 45 days following Unum's receipt of your appeal request. If Unum determines that special circumstances require an extension of time for a decision on review, the review period may be extended by an additional 45 days (90 days in total). Unum will notify you in writing if an additional 45-day extension is needed.

If an extension is necessary due to your failure to submit the information necessary to decide the appeal, the notice of extension will specifically describe the required information, and you will have at least 45 days to provide the specified information. If you deliver the requested information within the time specified, the 45 day extension of the appeal period will begin after you have provided that information. If you fail to deliver the requested information within the time specified, Unum may decide your appeal without that information.

You will have the opportunity to submit written comments, documents, or other information in support of your appeal. You will have access to all relevant documents as defined by applicable U.S. Department of Labor regulations. The review of the claim denial will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination.

A person who is not involved in the initial claim determination will conduct the appeal review and such person will not work under the original decision maker's authority. In the case of a claim denied on the grounds of a medical judgment, Unum will consult with a health professional with appropriate training and experience. The health care professional who is consulted on appeal will not be the individual who was consulted during the initial determination or a subordinate. If the advice of a medical or vocational expert was obtained by the Plan in connection with the denial of your claim, Unum will provide you with the names of each such expert, regardless of whether the advice was relied upon.

A notice that your request on appeal is denied will contain the following information:

• The specific reason(s) for the determination;
• A reference to the specific Plan provision(s) on which the determination is based;
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or a statement that such information will be provided free of charge upon request);
• A statement describing your right to bring a lawsuit under Section 502(a) of ERISA if you disagree with the decision;
• The statement that you are entitled to receive upon request, and without charge, reasonable access to or copies of all documents, records or other information relevant to the determination; and
• The statement that "You or your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency".

Notice of the determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements.

Unless there are special circumstances, this administrative appeal process must be completed before you begin any legal action regarding your claim.