Summary of Coverage

The following general summary of features on Fortis Health's Short Term Medical plan may vary according to the state in which the insured resides. This summary is not an insurance contract. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. Once you receive your Short Term Medical policy, please read it carefully.

Short Term Medical is designed to provide coverage for major hospital, medical and surgical expenses incurred as a result of medically necessary care for a covered illness or injury. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital services, and out-of-hospital care, subject to any deductibles or rate of payment provisions or other limitations which may be set forth in the policy.

A covered illness or injury is an expense that is: 1) incurred for services, treatment or supplies prescribed by a physician; 2) incurred by a covered person as the result of sickness or injury; 3) incurred for medically necessary care; and 4) incurred while this policy is in force.

Covered Medical Services

The following general summary of covered medical services may vary according to the state in which the insured resides.

• Covered charges incurred for: physician and surgical services.
• Covered charges incurred for drugs which require the written prescription of a physician.
• Covered charges incurred for: room, board and routine nursing services that are generally provided to all persons while confined in a hospital. If the covered person is confined in a private room, only charges up to the average semi-private rate of the hospital are covered.
• Covered charges incurred for outpatient medical care and treatment provided by a hospital or freestanding ambulatory surgical facility.
• Covered charges incurred for x-ray, radioactive treatment, laboratory and anesthesia services, including one screening mammographic exam per benefit period for a covered female, age 35 or over.
• Covered charges incurred for the first 30 days of confinement in a rehabilitation or skilled nursing facility for the covered person per benefit period.
• Covered charges incurred for the first 40 home health care visits for the covered person per benefit period.
• Covered charges incurred for up to 10 outpatient physical medicine visits for the covered person per benefit period. (Includes chiropractic care in most states.)
• Covered charges incurred for professional ambulance service to the nearest hospital that is able to handle the sickness or injury.
• Covered charges incurred for rental (not to exceed the purchase price) of one basic manual wheelchair, one basic hospital bed, one pair of basic crutches, the initial permanent basic artificial limb or eye and oxygen and the basic equipment needed to administer oxygen; and the initial external breast prosthesis needed because of the medically necessary surgical removal of all or part of the breast, provided the surgical removal was done while the covered person was covered under the plan.
• Covered charges incurred for reconstructive surgery required due to an injury which occurred while the covered person is insured under the plan.
• Covered charges incurred for surgical treatment of temporomandibular joint (TMJ) or craniomandibular joint (CMJ) dysfunction, provided the charges are for services included in a dental treatment plan authorized by Fortis Health prior to the surgery; charges for nonsurgical treatment of TMJ or CMJ.
• Covered charges incurred for the following complications of pregnancy: spontaneous termination of pregnancy (miscarriage) which occurs before the 26th week of gestation; missed abortion (miscarriage); ectopic pregnancy when pregnancy is ended; and other medical conditions such as acute nephritis, nephrosis and cardiac decompensation.
• Covered charges incurred for the following organ transplants: heart, liver, and bone marrow. Tissue transplants include: cornea transplant; prosthetic tissue replacement, including joint replacement; vein or artery graft; heart valve replacement; and implantable prosthetic lens in connection with cataracts. The maximum amount we will pay for any and all organ transplants is limited to $250,000 for the covered person during his or her lifetime.
• Covered expense incurred for the treatment of AIDS, AIDS Related Complex (ARC) or related immuno deficiency disorders.

Extension of Benefits: When the benefit period expires, coverage may be extended for a continuous injury sustained or sickness which commenced while the policy was in force and for which a covered person is then being treated. The extension of benefits provision will apply when:

1. The covered person receiving treatment remains totally disabled beyond the benefit period expiration date and is under the care of a physician for the disability during the benefit period.
2. The covered person who has met his or her deductible during the benefit period and is being treated for complications of or needs follow-up treatment for an injury sustained or sickness which commenced during the benefit period.