MetLife Hospital Indemnity Coverage (HIC)
Hospital Indemnity Coverage (HIC) provides benefits for you and your eligible dependents if you are admitted into a hospital as an inpatient due to a covered sickness or injury. The levels of daily coverage are $50 or $150.
Benefits Summary
Plan Documents & Resources
Exclusions & Limitations
Contact Info
Customer Service
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Hospital Indemnity Coverage
Unexpected hospital stays can mean lost time and lost income, which can make it hard to keep up with bills and things at home. Hospital Indemnity Coverage (HIC) pays you a set amount for every day you are in the hospital, for a covered sickness or injury, so you can rest easier.
The Employee must be enrolled for coverage in order to enroll your dependent(s).
If a child is born to anyone under this policy while family coverage is in force, the child shall automatically become a covered dependent from the moment of birth. However, you must still contact the FBMC Service Center at 1-855-MDC-PS4U (1-855-632-7748) and request a Change in Status form. This includes coverage for sickness or injury, and the necessary care and treatment of medically diagnosed congenital defects, birth abnormalities and premature birth. Routine care for the child is not covered under this policy.
Summary of Benefits
Definitions
“Physician” means:
- A person licensed to practice medicine and prescribe and administer drugs or to perform Surgery in the jurisdiction where such services are performed; or
- A medical practitioner who is licensed to provide a service for which a benefit is payable under this Certificate, according to the laws and regulations of the jurisdiction where such service is performed, and who is acting within the scope of such license.
The term Physician does not include:
- You;
- Your Spouse or anyone to whom You are related by blood or marriage;
- anyone with whom You are residing;
- Your adopted or stepchild;
- anyone with whom You share a business interest; or
- Your employee.
“Hospital” means a short-term, acute care, general facility which:
- Is primarily engaged in providing, by or under the continuous supervision of Physicians, to inpatients, diagnostic and therapeutic services for diagnosis, treatment and care of injured or sick persons;
- Has organized departments of medicine;
- Has facilities for major Surgery either on its premises or through contractual arrangement with another Hospital;
- Has a requirement that every patient must be under the care of a Physician or dentist;
- Provides 24-hour nursing service by or under the supervision of a registered professional nurse (R.N.);
- Is duly licensed by the agency responsible for licensing such Hospitals; and
- Is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the aged, a place for drug addicts or alcoholics, or a place for convalescent, custodial, or educational care.
The term Hospital does not include a separate unit of a hospital that is licensed as a hospice facility, nursing home, skilled nursing facility, assisted living facility, rehabilitation facility, or an outpatient surgery facility.
“Confined or Confinement” means the assignment to a bed as a resident inpatient in a Hospital (including an Intensive Care Unit of a Hospital) on the advice of a Physician or confinement in an observation area within a Hospital for a period of no less than 20 continuous hours on the advice of a Physician.
Effective Date Provision
An insured’s coverage begins on the effective date shown in the issued Certificate of Insurance, subject to receipt of the correct initial premium and provided the person is considered to be actively at work.
Termination Provision
An insured’s coverage will end on the earliest of:
- if no longer an eligible employee/retiree of the policy holder;
- if required premium is not paid by the end of the grace period;
- the date the group policy is terminated;
- the date coverage is terminated for the class of eligible persons to which the insured belongs;
- the date you die.
Benefit Eligibility
- All Full-Time employees and Part-time employees are eligible to enroll in the Hospital Indemnity Coverage offered by the School Board.
- COBRA participants will be given the opportunity to enroll in Hospital Indemnity Coverage directly with MetLife by calling 1-866-626-3705.
Plan Documents & Resources
Limitations and Exclusions
PLEASE NOTE:
Exclusions and limitations in any policy and certificate issued will be based on the policyholder’s situs state, plan design and states where employees reside. If the policyholder has employees residing in the following states, that state’s Exclusions and Limitations will apply: Alaska, Arkansas, Connecticut, Louisiana, Minnesota, Mississippi, Montana, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, South Carolina, Texas, Utah, Vermont, Washington, West Virginia, and Wisconsin.
How to read this section:
Exclusions appear in bold font. Applicable state variations are noted in italics.
We will not pay benefits for any loss due to an Accident or Sickness for a covered person caused or contributed to by any of the following:
- the covered person’s voluntary use, by any means, of:
- any drug, medication or sedative, unless it is:
- taken or used as prescribed by a physician; or
- an “over the counter” drug, medication or sedative taken as directed
- alcohol in combination with any drug, medication, or sedative
- poison, gas, or fumes
- the covered person’s suicide or attempted suicide (while sane or insane)
- the covered person’s intentionally self-inflicted injury
- war, whether declared or undeclared; or act of war
- the covered person’s active participation in an insurrection, rebellion, riot, or terrorist act
- the covered person’s engagement in any activity that constitutes a felony under the laws of the jurisdiction in which the activity occurred
- dental procedures or surgery except as the result of an Accident causing Injury to a sound natural tooth
- cosmetic surgery, except when such surgery is performed to:
- treat an Injury or Sickness;
- correct a disorder of normal bodily function or structure that was caused by an Injury or Sickness for which coverage is not otherwise excluded under the certificate; or
- reconstruct a part of the body which was disfigured or removed as a result of an Injury or Sickness for which coverage is not otherwise excluded under the certificate
- the covered person’s mental illness, or the diagnosis or treatment of such mental illness, except for the covered person’s use of:
- any drug, medication or sedative that is taken or used as prescribed by a Physician; or
- an “over the counter” drug, medication or sedative taken as directed
- activities required by the covered person to carry out the duties and responsibilities of their service in the armed forces or any auxiliary unit of the armed forces of any country or international authority
In addition, We will not pay benefits for:
- a covered person while incarcerated in any type of penal or detention facility
- any of the following outside of the United States, Canada or Mexico:
- any medical or healthcare treatment, services or transportation; or
- any inpatient admission or stay in any medical or health care facility
The following additional exclusions apply to payment of benefits for any loss due to an Accident:
We will not pay benefits for any loss due to an Accident for a covered person caused or contributed to by any of the following:
- the covered person’s operation, while intoxicated, of a motor vehicle involved in the incident. For purposes of this exclusion:
- intoxicated means that the covered person’s blood alcohol level met or exceeded .08%; and
- motor vehicle means any vehicle that is powered by a motor, including, but not limited to: an automobile; a boat; a motorcycle; a truck; an all-terrain vehicle; or a snow mobile
- the covered person’s travel or flight in any aircraft except as a fare-paying passenger on a regularly scheduled charter or commercial flight
- the covered person parachuting or otherwise exiting from a motorized or non-motorized aircraft while such aircraft is in flight, except for self-preservation
- the covered person riding in or driving any motor-driven vehicle in a race, stunt show or speed test
- the covered person participating in any semi-professional or professional competitive athletic activity for which any type of compensation or remuneration is received
- the covered person bungee jumping, base jumping, hang gliding, para-kiting, sail-gliding, scuba diving deeper than 130 feet; spelunking; or mountaineering including rock climbing using ropes and any other climbing equipment for the purposes of this exclusion the term mountaineering does not include backpacking, mountain biking, hiking or trail running
The following additional exclusions apply to payment of benefits for any loss due to a Sickness:
We will not pay benefits under the certificate for:
- a dependent child’s routine pregnancy or routine childbirth and any well baby or nursing care provided to the dependent child’s newborn child
- the covered person’s alcoholism, drug addiction, chemical dependency or complications thereof