1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

DOCUMENTPRF.PARED 

ON RECYCLED PAPER 

GERARD G. PECHT (Admitted Pro Hac Vice) 

gerard.pecht@nortonrosefulbright.com 

NORTON ROSE FULBRIGHT US LLP 

1301 McKinney, Suite 5100 

Houston, Texas 77010-3095 

Telephone: (713) 651-5151 

Facsimile: (713) 651-5246 . 

M. SCOTT INCERTO (Admitted Pro Hac Vice) 

scott.incerto@nortonrosefulbright.com 

NORTON ROSE FULBRIGHT US LLP 

98 San Jacinto Boulevard, Suite 1100 

Austin, Texas 78701-4255 

Telephone: (512) 474-5201 

Facsimile: (512) 536-4598 

JOSHUA D. LICHTMAN (SBN 176143) 

joshua.lichtman@nortonrosefulbright.com 

MICHELLE L. MELLO (SBN 288081) 

michelle.mello@nortonrosefulbright.com 

NORTON ROSE FULBRIGHT US LLP 

555 South Flower Street, Forty-First Floor 

Los Angeles, California 90071 

Telephone: (213) 892-9200 

Facsimile: (213) 892-9494 

Attorneys for Defendants 

HCC LIFE INSURANCE COMPANY and HCC 

MEDICAL INSURANCE SERVICES, LLC 

(erroneously sued as TOKIO MARINE HCC -

MEDICAL INSURANCE SERVICES GROUP) 

IN THE UNITED STATES DISTRICT COURT 

FOR THE NORTHERN DISTRICT OF CALIFORNIA- OAKLAND DIVISION 

MOHAMMED AZAD and DANIELLE 

BUCKLEY, on behalf of themselves and all 

others similarly situated, 

Plaintiffs, 

v. 

TOKIO MARINE HCC- MEDICAL 

INSURANCE SERVICES GROUP, HEALTH 

INSURANCE INNOVATIONS, INC., HCC 

LIFE INSURANCE COMPANY, and 

CONSUMER BENEFITS OF AMERICA, 

Defendants. 

Case No.: 4: 17-cv-00618-PJH 

DECLARATION OF JON PADGETT IN 

SUPPORT OF HCC LIFE INSURANCE 

COMPANY AND HCC MEDICAL 

INSURANCE SERVICES, LLC'S 

MOTION TO DISMISS AND THEIR 

ALTERNATIVE MOTION TO STRIKE 

CLASS ALLEGATIONS 

Date: May 24,2017 

Time: 9:00a.m. 

Ctrm: 3 

Complaint Filed: February 7, 2017 

Case No.: 4:17-cv-00618-PJH 

DECLARATION OF JON PADGETT 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 1 of 166
1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

DocUMENT PW.EI'ARED 

ON RECYCI.Ell PAJ>f.R 

I, Jon Padgett, hereby say and declare as follows: 

1. I am Vice President of Claims and Compliance at HCC Medical Insurance 

Services, LLC. HCC Medical Insurance Services, LLC administers Short Term Medical 

("ST.M") insurance policies i~sued by HCC Life Insurance Company ( collectiv~ly, "HCC"). I 

have worked for HCC for around ten (10) years, and have held my current position since January 

2015. As part of my duties and responsibilities, I am familiar with how the STM product is 

advertised, issued, and administered. I have personal knowledge of the matters set forth in this 

declaration and, if called as a witness, I could and would testify competently thereto. 

2. HCC's website, referenced at paragraphs 42-46, 49, 54 and footnotes 9 and 10 of 

the Class Action Complaint ("Complaint"), is located at http://www.hccmis.com. Attached 

hereto as Exhibits 1 through 10, are true and correct copies of certain materials, described further 

below, as they appeared on the HCC website as of the times when Plaintiffs Mohammed Azad 

and Danielle Buckley's purchases were made in, respectively, December 2015 and April2016. 

3. Exhibit 1 is a screenshot of the top portion of the HCC website homepage. 

4. Exhibit 2 is a screenshot of the "Products" tab of the HCC website homepage. 

5. Exhibits 3, 4, and 5 are screenshots depicting three sets of steps a user ofthe HCC 

website could have followed to view the "Short-Term Medical" product description page of the 

HCC website in April2016. A user of the HCC website could have taken either of the two sets of 

steps depicted in Exhibits 3 and 4 to view the "Short-Term Medical" product page in December 

2015. 

6. Exhibit 6 is a screenshot of the "California Short-Term Medical Insurance Plans" 

product page ofthe HCC website, as was linked from the "Short-Term Medical" product page. 

7. Exhibit 7 is a specimen California STM Certificate, referenced at paragraph 54 of 

the Complaint, and Exhibit 8 is a screenshot demonstrating its link from the "California ShortTerm Medical Insurance Plans" product page (Exhibit 6). 

8. Exhibits 9 and 10 are screenshots depicting two sets of steps a user of the HCC 

website could have followed to view or download the "exemplar" "CA STM Complete" brochure 

referenced at paragraphs 42, 43, 44, 46, and 49 of the Complaint, and Exhibit 11 is that brochure. 

- 1 - Case No.: 4:17-cv-00618~PJH 

DECLARATION OF JON PADGETT 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 2 of 166
Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 3 of 166
EXHIBIT 1 

! . 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 4 of 166
Exhibit 1

800 2282 Sign In 1 0. 

Temporary 

Insurance for U.S. 

Residents 

You are a U.S. resident in need of 

health insurance. We'll keep you 

covered for the short-term. 

Tell Me More! 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 5 of 166
EXHIBIT 2 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 6 of 166
Exhibit 2

Hcc::.....~ 

Health Insurance 

for International 

Travelers 

ThiS IS Mel 

--ll&llorl l q 

Temporary 

Insurance for U.S. 

Residents 

Tell Me Morel 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 7 of 166
EXHIBIT 3 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 8 of 166
Exhibit 3

Step One:

Step Two:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 9 of 166
Step Three:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 10 of 166
EXHIBIT 4 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 11 of 166
Exhibit 4

Step One:

Step Two:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 12 of 166
Step Three:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 13 of 166
EXHIBIT 5 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 14 of 166
Exhibit 5

Step One:

Step Two:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 15 of 166
Step Three:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 16 of 166
EXHIBIT 6 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 17 of 166
Exhibit 6

Step One:

r., HCC --- --

Short Term Medical Insurance t!((~ SI>Orl ~"'~~t~PO .Y'"'.&;I!Io.._ _~klt~~v-.n 'SIOCI'I>"91or--··t~Ot 

ll>tlr ,~~lo't's ~cr--. WU>¥1 H((. U(" ShOt\ T- MliCioQI CM*V.,:.. ~fii(Jrw 11'14--~ f'laVOII """$ «trw-•"'-'"'"'*' -~ UM-..blr,-..-,.-~tt~o;t .. et--oeto,.euo.-Uwtt rcu...,.~rJ ~ 

~~ mtdlc4 ell---· Cllt" 10 ........ ,,_., .tKul '-' $1>Grt f!<"'>MI$ul --Qt>llt""""' ..... In .. ,. 

"~d ,, 

Get Short Term Insurance 

Pl.._-~, OUt $1-' 1 ..... M<!dk"l loo_..,_ k lnl<rOifl ... IO< I~ IO MT.,..,..In 11 ,, _ ... -. II 1 .. nol or>not>ll""' 

-'l thef~ .. "''~C'..,oe~ .w>dd---~·~~ .. t'fd~p•oe ot~~l~(.,....._ 

Select Your State: 

a..e~· 

....... 

...,. 

,_ 

....

·-. Kl ...... .._, 

...,.,.~ 

-· -~ 

~·­ ~-·-

--····--... _... 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 18 of 166
Step Two:

HOME PRODUCTS • CUSTOMER SERVICE • PRODUCERS • SLOG 

California Short Term Medical Insurance Plans ~\fO~""' Our •ntemi'ltiot\lll prov•cler network mdud~ over- 370,000 hei'l!th <~re 

(ll1~ prdi:ss•Mols ¥1d fltt•hbcs tn. Qllifom•i'l lllont:l F•nd a Doctor'" the network 

he~. 

Get f'O()te dtta•ls teoarclirlg an the benents ava!l.aDie In <:airornia wlm our 

shott term meo1ca1 ns~nce plan rJt re ... iewlng the fU 1 poucy documerns 

here. 

Short term medicallnsura,1oe from HCC Life Josuraoce PfOvldes polkles to Ca!lfotnla l'eSidetlts 

need!ng health ca•·e covecage. Tempora.y health lnsuraoce plans are availabieo in a range of 

deductibles a.nd do not require a pttmary cal\'! ph'(Sidan. In Catlfomia. reSi~ t covesage 

itw:ludes screMing> and other J)lf!\•entative C¥e. Short term m edical insurKtce plans In 

Califomia also indude c.hil~specltic services. 

General STM Benefits 

Deductible 01Qiices· $500, !>l,OOO, $'2:,500. sS,OOO ¥ld s7,SOO 

No Rerenals t."eeoea ror SP«iallSts Excep( Physical th«apy 

NO Prim(l(y cz.·e PhysiCian fl.eQuicea 

Out·or4 Networ'l< coveraoe 

ChOICe or 80/ 20% Of SO/SO% COtOSOfallce 

Covefage M<numum up to Sl,OOO,OOO ure.:rme 

Hospital p<~tleot Presulptlo•l Drug coverage 

Lab/lH·ay, Emergency Room, Outpatient SUrg@l)' & Hospitalization co .. erage 

California-Specific STM Benefits 

Periodic M<\mmogr~m x~:~ms Beg•nntng t Age: 3S 

Cc:rvKol C<1ncc:r Screc:rungs lndudtng P;)p Te$t 

Chid r~vent;)t•ve C<1re and Chi dhood JmmUillli't•ons up to ;.,gc 16 

ent"l Hc:.,lth Cove•·.,oe 

Dental Anesthesia 

Cover~oe f« r4ecllea!ly Ne¢et£ary Pr<>ttMtlc C>evlcet After Ur)'l'\QeC~()IYiy Goroe.tv 

Prost<Ke SCiteOnlOS 

Osteoporosis Management aO<I Treatment 

Diabetes. St4)plles 

AIDS V&ednation 

cance-r Clfnic.al Ti1als 

Tceatment for the Ph~ ylketonurla Birth Defect 

cancer screening Te ~ 

SHORT TERM MEDICAL 

Short: t erm he.afth ios.t.rance for 

tempor&ry gaps in <:oV"erage. 

lEARN MORE 

or 

G"l a Quot~ 

Pre·e>ciSOOO e<~ lltions exchJ<le<l 

-:"'""'l!l!"".,;.""!..,..,,..""'""' !:f;, eo cover'8oe Is our<tlase<J 'W1 til in ouee Clavs or cne -effect•ve <1J te. •NalUOO perio<J Clo-es not 

aocl'( to lf\lu•1es. 

Fofill(llvl(fual heaiiD nl surJfKe purcnaslno oui<Jes ano suooestiOf'IS, see the Cl'llromla De1>anment or lnsuraoc:e Resoun:e: 

www .lns.urance. ca .gov 

There are transitional pertods In life th21t can le&ve you Without medical coye.rage for a b1tef time. HCC fotedicaltosur.:mce Services 

understands vour need ior peace of mind abata. health insurance cover-age during unce11ain es. 

Get Short Te1 m Insurance 

RESOURCES 

tmpoet ant rnfo. mauon 

Privacy Polley 

Te-ms of use Leoaa Notice 

ABOUT US 

About Tokb Marir'h;- HCC MtS Gr-oup 

Contact Us 

Site Map 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 19 of 166
EXHIBIT 7 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 20 of 166
HCCL STMM 102 CA 1 

HCC LIFE INSURANCE COMPANY 

225 TownPark Drive, Suite 350 

Kennesaw, Georgia 30144 

866-400-7102 

CERTIFICATE OF INSURANCE 

PROVIDING SHORT TERM MAJOR MEDICAL INSURANCE 

Group Policy No. STM600-1 (“the policy”), has been issued to Consumer Benefits of America 

which we will refer to as “the Policyholder”. We will refer to HCC Life Insurance Company as 

“the Company”, “we”, “us”, “our”. 

The policy was delivered in Missouri and will be governed by the laws thereof. 

This Certificate of Insurance is evidence of the Insured’s insurance under the policy and of its 

benefits. Everything contained in this Certificate of Insurance is subject to the provisions, 

definitions, and exceptions in the policy. The policy is on file with the Policyholder and may be 

examined at any reasonable time. Only one of our executive officers can authorize a change of 

the policy. 

This Certificate replaces all Certificates and Certificate Riders, if any, previously issued to the 

Insured under the policy. 

Signed for HCC Life Insurance Company. 

President 

THIS CERTIFICATE IS EVIDENCE OF A CONTRACT 

BETWEEN THE POLICYHOLDER AND THE COMPANY 

READ IT CAREFULLY

For service or complaints about this policy, please address any inquiries to 

the address shown above or call 866-400-7102. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 21 of 166
HCCL STMM 102 CA 2 

TABLE OF CONTENTS 

PART I GENERAL DEFINITIONS ................................................................ Page 3 

PART II ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE ........................ Page 7 

PART III TERMINATION OF INSURANCE ..................................................... Page 8 

PART IV PREMIUMS ...........................................................................................Page 10 

PART V DESCRIPTION OF MEDICAL EXPENSES ...................................... Page 11 

PART VI EXCLUSIONS........................................................................................Page 18 

PART VII COORDINATION OF BENEFITS ..........................................................Page 22 

PART VIII CLAIM PROVISIONS .................................................................................. Page 25 

PART IX GENERAL PROVISIONS ......................................................................Page 27 

PART X SCHEDULE OF BENEFITS ................................................................ Page 28 

OPTIONAL BENEFIT RIDERS, IF ANY 

AMENDMENT RIDERS, IF ANY 

NOTE: NO CONTINUOUS COVERAGE. This Certificate of insurance provides coverage 

for a short term duration only. It is not renewable. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 22 of 166
HCCL STMM 102 CA 3 

PART I – GENERAL DEFINITIONS 

“Accident” means a sudden, unforeseeable event that causes injury to one or more Covered 

Persons. 

“Complications of Pregnancy” means: 

1. Conditions requiring Inpatient treatment (when pregnancy is not terminated); 

2. Whose diagnoses are distinct from pregnancy but are adversely affected or caused by 

pregnancy, such as hyperemesis gravidarum, preeclampsia, acute nephritis, nephrosis, 

cardiac decompensation, missed abortion and similar medical and surgical conditions of 

comparable severity, but shall not include false labor, occasional spotting, Doctor 

prescribed rest during the period of pregnancy, morning Sickness, and other similar 

conditions associated with the management of a difficult pregnancy not constituting a 

nosologically distinct complication of pregnancy; and 

3. Non-scheduled or emergency cesarean section, ectopic pregnancy that is terminated, 

and spontaneous termination of pregnancy that occurs during a period of gestation in 

which a viable birth is not possible. 

“Congenital Condition” means a disease or other anomaly existing at or before birth, whether 

acquired during development or by heredity. 

“Coverage Period” means the length of time which the Insured selected in the Insured’s 

application and approved by us, not to exceed a month period commencing on the 

Effective Date. The Insured’s Coverage Period is shown in the Schedule of Benefits. 

“Covered Person” means an Insured and his eligible dependents for whom coverage is in effect 

under the policy, as described in Part II – Eligibility and Effective Date of Insurance Provisions 

and the Schedule of Benefits. 

“Custodial or Convalescence Care” means any care that is provided to a Covered Person who 

is disabled and needs help to support the essential activities of daily living when the Covered 

Person is not under active and specific medical, surgical, or psychiatric treatment that will 

reduce the disability to the extent necessary for the person to perform the essentials of daily 

living on his own. 

“Deductible” means the amount of covered expenses that must be paid by a Covered Person 

before benefits are payable under the policy. This amount applies separately to each Covered 

Person and must be satisfied each Coverage Period. 

“Doctor” means any duly licensed practitioner who is recognized by the law of the state in which 

treatment is received as qualified to perform the service for which claim is made. 

“Eligible Dependent” means: 

1. The Insured’s lawful spouse; and 

2. The Insured’s unmarried children who are less than age 19. An unmarried child who is 

less than age 25 may also be included if the child is enrolled full-time in an accredited 

school or college. 

Dependent children may include stepchildren, foster children, legally adopted children, children 

of adopting parents pending finalization of adoption procedures, and children for whom 

coverage has been court-ordered. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 23 of 166
HCCL STMM 102 CA 4 

Dependent children (other than those for whom coverage has been court-ordered) must be 

primarily dependent on the Insured for principal support and maintenance. 

Coverage for an unmarried dependent child who is: 

A. incapable of self sustaining employment by reason of a physically or mentally disabling 

injury, illness or condition; who became so incapacitated prior to the attainment of the 

limiting age set forth above, and 

B. chiefly dependent upon the Insured for support and maintenance, shall not terminate. 

Coverage shall continue as long as the certificate remains in force and the dependent is 

disabled. Proof of such incapacity and dependency must be furnished to Us within sixty 

(60) of receipt of notice by Us that such coverage will terminate. We will provide such 

notice at least 90 days prior to the date the Dependent child attains the limiting age. 

Continued proof may be requested, but not more frequently than once a year. 

“Durable Medical Equipment” means medical equipment that can withstand repeated use, is 

prescribed by a Physician, and is appropriate for use in the home. Covered DME is limited to a 

standard basic Hospital bed and/or a standard basic wheel chair. 

“Effective Date” means the date the Insured’s (and Eligible Dependents’ if applicable) coverage 

under the policy is effective. 

“Experimental Treatment” means in Our discretion a treatment, drug, device, procedure, supply 

or service and related services (or any portion thereof, including the form, administration or 

dosage) for a particular diagnosis or condition when any one of the following exists: 

1. The treatment, drug, device, procedure, supply or service is in any clinical trial or a 

Phase I, II or III trial. 

2. The treatment, drug, device, procedure, supply or service is not yet fully approved or 

recognized (for other than experimental, investigational, research or clinical trial 

purposes) by the National Cancer Institute (NCI), Food & Drug Administration (FDA), or 

other pertinent governmental agency or professional organization. 

3. The results are not proven through controlled clinical trials with results published in peerreviewed English language medical journals, to be of greater safety and efficacy than 

conventional treatment, in both the short and long term. 

4. The treatment, drug, device, procedure, supply or service is not generally accepted 

medical practice in the state where the Covered Person resides or as generally accepted 

throughout the United States as determined in Our discretion, by reference to any one or 

more of the following: peer-reviewed English-language medical literature, consultation 

with physicians, authoritative medical compendia, the American Medical Association, or 

other pertinent professional organization or governmental agency. 

5. The treatment, drug, device, procedure, supply or service is described as investigational, 

experimental, a study, or for research or the like in any consent, release or authorization 

which the Covered Person, or someone acting on his or her behalf, may be required to 

sign. 

The fact that a procedure, service, supply, treatment, drug, or device may be the only hope for 

survival will not change the fact that it is otherwise experimental in nature. 

“Extended Care Facility” means an institution, other than a Hospital, operated and licensed 

pursuant to law, that provides: 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 24 of 166
HCCL STMM 102 CA 5 

1. Permanent and full-time facilities for the continuous skilled nursing care of three (3) or 

more sick or injured persons on an Inpatient basis during the convalescent stage of their 

illnesses or injuries; 

2. Full-time supervision of a Doctor; 

3. Twenty-four (24) hour a day nursing service of one or more Nurses; and 

4. Is not, other than incidentally, a rest home or a home for custodial care or for the aged. 

Extended Care Facility does not include an institution that primarily engages in the care 

and treatment of drug addiction or alcoholism. 

“Home Health Care Agency” means an entity licensed by state or local law operated primarily to 

provide skilled nursing care and therapeutic services in an individual’s home and: 

1. Which maintains clinical records on each patient; 

2. Whose services are under the supervision of a Doctor or a licensed graduate registered 

nurse (RN); and 

3. Which maintains operational policies established by a professional group including at 

least one Doctor and one licensed graduate registered nurse (RN). 

“Home Health Care Plan” means a program for continued care and treatment of an individual 

established and approved in writing by the individual’s attending Doctor. As part of the plan, an 

attending Doctor must certify that proper treatment of the Injury or Sickness would require 

continued confinement in a Hospital in the absence of the services and supplies. 

“Hospital” means an institution operated by law for the care and treatment of injured or sick 

persons; has organized facilities for diagnosis and surgery or has a contract with another 

hospital for these services; and has 24-hour nursing service. Hospital excludes any institution 

that is primarily a rest home, nursing home, convalescent home, a home for the aged, an 

alcoholism or drug addiction treatment facility. 

“Immediate Family” means the parents, spouse, children, or siblings of a Covered Person, or 

any person residing with a Covered Person. 

“Injury” means accidental bodily Injury of a Covered Person: 

1. Caused by an Accident; and 

2. That results in covered loss directly and independently of all other causes. 

All Injuries sustained in one Accident, including all related conditions and recurring symptoms of 

the Injuries, will be considered one injury. 

“Inpatient” means a person who incurs medical expenses for at least one day’s room and board 

from a Hospital. 

“Insured” means a person who meets the eligibility requirements for an Insured as stated in the 

Master Application and the policy, and whose coverage under the policy has become effective 

and has not terminated. 

“Medically Necessary” means the care, service or supply is: 

1. Prescribed by a Doctor for the diagnosis or treatment of an Injury or Sickness; and 

2. Appropriate, according to conventional medical practice for the Injury or Sickness in the 

locality in which the care, service or supply, is given. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 25 of 166
HCCL STMM 102 CA 6 

“Mental and Nervous Disorder” means a “biologically-based” mental disorder, including 

Schizophrenia, Schizoaffective disorder, Major depressive disorder, Bipolar disorder, Paranoia 

and other psychotic disorders, Obsessive-compulsive disorder, Panic disorder, Delirium and 

dementia, Affective disorders, and any other "biologically-based" mental disorders appearing in 

the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric 

Association (the "DSM"). 

“Outpatient” means a person who incurs medical expenses at Doctor’s offices and freestanding 

clinics, and at Hospitals when not admitted as an Inpatient. 

“Regular and Customary Activities” means an Insured Person can carry on a substantial part of 

the standard and commonly practiced activities of a person in good health of the same sex and 

age. Activities performed while confined in a Hospital or other medical institution may not be 

used to meet this requirement. 

“Routine Physical Exam” means examination of the physical body by a Doctor for preventive or 

informative purposes only, and not for the diagnosis or treatment of any condition. 

“Sickness” means Sickness or disease of a Covered Person that: 

1. Is treated by a Doctor while the person is covered under the policy; and 

2. Results directly and independently of all other causes in loss covered by the policy. 

“Substance Abuse” means the overindulgence in and dependence on a psychoactive leading to 

effects that are detrimental to the individual's physical health or mental health, or the welfare of 

others. 

“Surgery or Surgical Procedure” means an invasive diagnostic procedure; or the treatment of 

Injury or Sickness by manual or instrumental operations performed by a Doctor while the patient 

is under general or local anesthesia. 

“Total Disability” (or “Totally Disabled”) means the Insured is disabled and prevented from 

performing the material and substantial duties of his or her occupation. For Dependents, 

“Totally Disabled” means the inability to perform a majority of the normal activities of a person of 

like age in good health. 

“Urgent Care Center” means a medical facility separate from a hospital emergency department 

where ambulatory patients can be treated on a walk-in basis without an appointment and 

receive immediate, non-routine urgent care for an Injury or Sickness presented on an episodic 

basis. 

“Usual and Customary” charges means the following: 

1. A usual fee is defined as the charge made for a given service by a Doctor to the majority 

of his or her patients; and 

2. A customary fee is one that is charged by the majority of Doctors within a community for 

the same services. All benefits are limited to Usual and Customary charges. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 26 of 166
HCCL STMM 102 CA 7 

PART II – ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE 

Coverage will be effective for an Insured and his Eligible Dependent(s) as of the approved 

Effective Date, provided: 

1. The Insured meets the eligibility requirements set forth in the Master Application and the 

Policy; 

2. The Insured's Application is approved by Us; 

3. The first premium payment is received on or before the date the Insured's Application is 

approved by Us; 

4. The Insured is not confined at home or in a Hospital or medical institution as of the 

Effective date; and 

5. The Insured is engaging in his Regular and Customary Activities as of the Effective date. 

If the Insured is not engaged in his Regular and Customary Activities or is confined in a Hospital 

or medical institution on the Effective Date, coverage will begin the first day he can engage in 

his Regular and Customary Activities and is not confined in a Hospital or medical institution. 

The Company will require satisfactory evidence of insurability for each Insured and Eligible 

Dependent. 

Newborn Child Coverage: A child of the Insured born while the policy is in force is covered for 

Injury and Sickness (including necessary care and treatment of congenital defects, birth 

abnormality and premature birth), as well as routine newborn care for the first 31 days. The 

child is covered from the moment of birth until the 31st day of age. A notice of birth together with 

additional premium must be submitted to us within 31 days of the birth in order to continue 

coverage for Injury and Sickness beyond the initial 31-day period. 

Adopted Children Coverage: A minor child who comes under the charge, care and control of 

the Insured while the policy is in force is covered for Injury and Sickness provided the Insured 

files a petition to adopt. The coverage of such child will be the same as provided for other 

members of the Insured’s family. Such child shall be covered from the date of placement in the 

Insured’s home if the Insured applies for coverage and pays any required premium within 31 

days after the date of placement. However, coverage shall begin at the moment of birth if the 

petition for adoption, application for coverage and payment of premium occurs within 31 days 

after the child’s birth. Such child’s coverage will not be subject to any pre-existing conditions 

limitation provided by the policy. Coverage for such minor child will continue unless the petition 

for adoption is dismissed or denied. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 27 of 166
HCCL STMM 102 CA 8 

PART III - TERMINATION OF INSURANCE 

Coverage of a Covered Person under the Policy shall automatically terminate on the earliest of 

the following dates: 

1. The date the Coverage Period expires; 

2. The first day of the month coinciding with or following the date other hospital, major 

medical, group health or other medical insurance coverage becomes effective for a 

Covered Person; 

3. The end of the last period for which the last required premium payment was made for 

the Insured’s or Covered Person’s insurance; 

4. The date a Covered Person receives the Coverage Period Maximum Benefit Amount; 

5. The date the Covered Person enters the armed forces of any country, state or 

international organization, other than for reserve duty of 30 days or less; 

6. The premium due date that coincides with or next follows the date on which the Insured 

is no longer eligible; 

7. For a Dependent spouse, the first day of the month following the date of divorce or legal 

separation from the Insured; or 

8. The date We specify that the Covered Person’s insurance is terminated because of: 

A. Failure to provide any signed release, consent, assignment or other documents 

requested by Us; 

B. Failure to fully cooperate with Us in the administration of the Policy; 

C. Material misrepresentation, fraud, or omission of information on any application 

form, or in requesting the receipt of benefits under the Policy; or 

D. Misuse of the Covered Person's identification card. 

At the death of an Insured, all rights and privileges as a Covered Person under the Policy will 

transfer to the surviving Dependent spouse. The Dependent spouse will then be considered an 

Insured instead of a Dependent. In the event the Dependent spouse remarries, coverage under 

the Policy for the Dependent Spouse and Dependent child(ren), if any, will end on the first day 

of the month following the date of that marriage. If no surviving Dependent spouse, or at the 

death of a surviving Dependent spouse, all rights and privileges as a Covered Person under the 

Policy will transfer to each Dependent child, if any, and he will be considered the Insured 

instead of a Dependent. 

If the Insured selected the Pay In Advance option in the Insured's Application and We received 

all required premium for the Coverage Period, premium will be reimbursed to the Insured for the 

period of time, if any, between the date coverage terminates in accordance with the above 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 28 of 166
HCCL STMM 102 CA 9 

provisions and the end of that Coverage Period. 

Extension of Benefits 

If a covered Bodily Injury or Sickness commences while the Policy is in force as to a Covered 

Person, benefits otherwise payable under the Policy for the Injury or Sickness causing the Total 

Disability will also be paid for any Eligible Expenses incurred after the termination of insurance 

for a Covered Person if, from the date of such termination to the date such expenses are 

incurred, the Covered Person is Totally Disabled by reason of such Injury or Sickness. Such 

benefits shall be payable only during the continuance of such disability until the earlier of: 

1. The date the Total Disability ends; 

2. The date when treatment for the Total Disability is no longer required; 

 3. The date following a time period equal to the Covered Person's Coverage Period, with a 

minimum of thirty (30) days not to exceed a maximum of ninety (90) days; 

 4. The date the Covered Person becomes eligible for any other group insurance plan 

providing coverage for the same conditions causing the Total Disability; or 

 5. The date the Coverage Period Maximum Benefit amount has been reached. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 29 of 166
HCCL STMM 102 CA 10 

PART IV - PREMIUMS 

1. Unless the Pay In Advance option has been chosen, premium due dates for an Insured 

will be on the Effective Date and then the same date of each following calendar month. 

If a month has fewer days than the scheduled premium due date, premium will be due 

on the last day of the month. All insurance shall be charged from and to the premium 

due date. 

2. If any change or clerical error affects premiums, an equitable adjustment in premiums 

shall be made on the premium due date next following the date of the change or the 

discovery of the error. Any premium adjustment that involves collecting earned 

premiums, or returning unearned premium shall be limited to the six (6) months 

immediately preceding the date of determination that the adjustment in premium should 

be made. 

3. Premiums shall be payable in advance to Us at Our Home Office. 

4. If the Insured has not given written notice to Us that insurance is to be terminated prior 

to the premium due date, a grace period of thirty-one (31) days beginning from the 

premium due date will be allowed for any premium after the first premium. If the Insured 

fails to pay premium before the grace period expires all coverage shall lapse as of the 

premium due date. 

5. The Policy does not share in the surplus earnings of the Company and no refund or 

assessment shall be made to the Policyholder, Insured, or Dependent of any excess or 

deficit earnings of the Company. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 30 of 166
HCCL STMM 102 CA 11 

PART V – DESCRIPTION OF MEDICAL EXPENSES 

Subject to the Deductible, Coinsurance and other limits set forth in PART X – SCHEDULE OF 

BENEFITS, the Company will pay the following expenses incurred while this insurance is in 

effect: 

1. Charges made by a Hospital for: 

A. Daily room and board and nursing services not to exceed the average semiprivate room rate; 

B. Daily room and board and nursing services in Intensive Care Unit; 

C. Use of operating, treatment or recovery room; 

D. Services and supplies which are routinely provided by the Hospital to persons for 

use while Inpatients; 

E. Emergency treatment of an Injury, even if Hospital confinement is not required; 

and 

F. Emergency treatment of a Sickness; however, an additional $250 Deductible will 

apply to emergency room charges unless the Covered Person is directly 

admitted to the Hospital as an Inpatient for further treatment of that Sickness. 

2. For Surgery at an Outpatient surgical facility, including services and supplies. 

3. For charges made by a Doctor for professional services. 

4. For charges made by a Doctor for Surgery. Charges for an assistant surgeon are 

covered up to 20% of the Usual and Customary charge of the primary surgeon. 

(Standby availability will not be deemed to be a covered charge.). 

5. For dressings, sutures, casts or other supplies which are Medically Necessary and 

administered by or under the supervision of a Doctor, but excluding nebulizers, oxygen 

tanks, diabetic supplies, other supplies for use or application at home, and all devices or 

supplies for repeat use at home, except Durable Medical Equipment as herein defined. 

6. For diagnostic testing using radiology, ultrasonographic or laboratory 

services 

(psychometric, intelligence, behavioral and educational testing are not included). 

7. For artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial 

limbs, 

but not the replacement or repair thereof. 

8. For reconstructive surgery performed to correct or repair abnormal structures of the body 

caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or 

disease: 

A. to im pro ve f unct ion; or 

B. to create a normal appearance, to the extent possible. 

9. Reconstructive breast surgery and prosthetic devices incident to a Mastectomy. 

Coverage will also be extended to include surgery on a non-diseased breast to establish 

symmetry with the diseased breast. As used in this benefit: 

A. “Mastectomy” means the surgical removal of all or part of a breast as a result of 

breast cancer. 

B. “Reconstructive breast surgery” means surgery performed as a result of a 

mastectomy to reestablish symmetry between the two breasts and includes 

augmentation mammoplasty, reductive mammoplasty, and mastopexy. 

Coverage for prosthetic devices and reconstructive surgery means any initial or 

subsequent surgeries, prosthetic devices and any Medically Necessary follow up care. 

10. For radiation therapy or treatment and chemotherapy. 

11. For hemodialysis and the charges by the Hospital for processing and administration of 

blood or blood components but not the cost of the actual blood or blood components. 

12. For oxygen and other gasses and their administration by or under the 

supervision of a 

Doctor. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 31 of 166
HCCL STMM 102 CA 12 

13. For anesthetics and their administration by a Doctor, subject to a maximum of 20% of 

the benefit payable for the primary surgeon. 

14. Extended Care Facility charges for room and board accommodations; if: 

A. The Insured is an Inpatient in that facility on the certification of the attending 

Doctor that the confinement is Medically Necessary;

B. The confinement commences immediately following a period of at least three (3) 

continuous days of Hospital confinement; and 

C. That confinement is for the same covered Injury or Sickness that was treated 

during the Covered Person's confinement in the Hospital. 

15. Treatment of a Covered Person by a Home Health Care Agency under a Home Health 

Care Plan. Up to four (4) consecutive hours in a twenty-four (24) hour period of Home 

Health Care services shall be considered as one Home Health Care visit. Eligible 

Expenses for Home Health Care are the Maximum Allowable Charges made for the 

following: 

A. Part-time skilled nursing care; 

B. Ph ys ic a l t h e r a p y; 

C. S p e e c h t h e r a p y ; 

D. Medical supplies, drugs and medicines prescribed by a Doctor; 

E. Laboratory services by or on behalf of the Hospital but only to the extent benefits 

for those services would have been paid under the Policy had the Insured Person 

remained Hospitalized; 

F. Occupational therapy; and 

G. R e s p i r a t o r y t h e r a p y . However, benefits will not be paid for charges 

made by a Home Health Care Agency for: 

A. Any charges excluded under the Exclusions of the certificate; 

B. Full-time nursing care at home; 

C. Meals delivered to the home; 

D. Homemaker services; 

E. Any services of an individual who ordinarily resides in the Insured’s home or is a 

member of the Insured's immediate family; or 

F. Any transportation services. 

Benefits for Home Health Care are in lieu of any similar benefits provided under any 

other provision of the certificate. 

16. Local Ambulance transport necessarily incurred in connection with Injury, and Local 

Ambulance transport necessarily incurred in connection with Sickness resulting in 

Inpatient hospitalization. 

17. Dental treatment and dental surgery necessary to restore or replace natural teeth lost or 

damaged as a result of an Injury covered under this certificate. 

18. Medically Necessary rental of Durable Medical Equipment (limited to a standard basic 

hospital bed and/or a standard basic wheelchair) up to the purchase prices, not including 

expenses for customization and only for the portion of the cost equivalent to the 

Coverage Period. 

19. Physical Therapy if prescribed by a Doctor who is not affiliated with the Physical Therapy 

practice, necessarily incurred to continue recovery from a covered Injury or Sickness. 

Pre-Certification Requirements 

1. All hospitalizations, other Inpatient care, and Surgeries or Surgical Procedures must be 

Pre-certified. 

2. To comply with the Pre-certification requirements, the Covered Person must: 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 32 of 166
HCCL STMM 102 CA 13

A. Contact the Company at 1-866-400-7102 as soon as possible before the 

expense is to be incurred; and 

B. Comply with the instructions of the Company and submit any information or 

documents they require; and 

C. Notify all Doctors, Hospitals and other providers that this insurance contains Precertification requirements and ask them to fully cooperate with the Company.

 3. If the Covered Person complies with the Pre-certification requirements, and the 

expenses are Pre-certified, the Company will pay Eligible Medical Expenses subject to 

all terms, conditions, provisions and exclusions described in this certificate. If the 

Covered Person does not comply with the Pre-certification requirements or if the 

expenses are not Pre-certified: 

A. Eligible Medical Expenses will be reduced by 50%; and 

B. The Deductible will be subtracted from the remaining amount; and 

C. The Coinsurance will be applied. 

 4. Emergency Pre-certification: In the event of an emergency Hospital admission, Precertification must be made within 48 hours after the admission, or as soon as is 

reasonably possible. 

 5. Pre-certification Does Not Guarantee Benefits – The fact that expenses are Pre-certified 

does not guarantee either payment of benefits or the amount of benefits. Eligibility for 

and payment of benefits are subject to all the terms, conditions, provisions and 

exclusions herein. 

 6. Concurrent Review – For Inpatient stays of any kind, the Company will Pre-certify a 

limited number of days of confinement. Additional days of Inpatient confinement may 

later be Pre-certified if a Covered Person receives prior approval. 

Pre-Certification Requirements for reconstructive surgery in connection with a mastectomy shall 

not be required in determining length of stay in a hospital following such surgery or procedure. 

Only a Doctor competent to evaluate the specific clinical issues involved in the care requested, 

can deny a request to authorize care for reconstructive surgery. 

State Mandated Benefits. 

The following benefits are mandated by applicable state law. All benefits will be subject to any 

inside benefit limitations set forth below, as well as the Coverage Period Maximum Benefit 

amounts shown on the Schedule of Benefits. 

 1. Dental Anesthesia – Coverage shall be provided for general anesthesia for dental care 

for a Dependent child if an underlying medical condition requires such anesthesia to be 

provided in a hospital or surgery center setting. Coverage shall only include payment 

for: 

A . a n e s t h e s i a ; a n d 

B . hospital or surgery center setting charges. 

The Dependent child must meet the following conditions: 

A. be under the age of seven (7); or 

B. be developmentally disabled, regardless of age; and 

C. it is determined that such child's health is compromised and general anesthesia 

is Medically Necessary. 

 2. Child Preventive Care - Coverage shall be provided for comprehensive child preventive 

care consistent with the following for children 16 years of age or younger: 

A. The recommendations for Preventive Pediatric Health Care, as adopted by the 

American Academy of Pediatrics of September 1987; 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 33 of 166
HCCL STMM 102 CA 14

B. The most current version of the Recommended Childhood Immunization 

Schedule/United States, jointly adopted by the: 

(a) American Academy of Pediatrics; 

(b) Advisory Committee on Immunization Practices; and 

(c) American Academy of Family Physicians; 

unless the State Department of Health Services determines, within 45 days of the 

published date of the schedule, that the schedule is not consistent with the 

purposes of this benefit provision. and 

C. Include benefits for: 

(a) periodic health evaluations; 

(b) immu nizat ions; an d 

(c) laboratory services in connection with periodic health evaluations. 

 3. Mammography Screening - Coverage shall be provided for the screening and

diagnosis of breast cancer based on the following: 

A. A baseline mammogram for a woman who is thirty-five (35) to forty (40) years of 

age; 

B. A mammogram for a woman who is forty (40) to forty-nine (49) years of age, 

every two years, or more frequently, based on the recommendation of the 

woman’s Doctor; 

C. A mammogram each year for a woman who is at least fifty years (50) of age; 

 4. Laryngectomy - Coverage shall be provided for prosthetic devices to restore speech 

after a laryngectomy. 

As used here: 

Laryngectomy means the Medically Necessary removal of the larynx. 

Prosthetic devices means initial and replacement prosthetic devices, including 

installation accessories prescribed by a Doctor. It does not include an electronic voice 

producing machine. 

 5. Prostate Screenings - Coverage shall be provided for the screening and diagnosis of 

prostate cancer. Coverage shall include, but not be limited to: 

A. prostate specific antigen testing; and 

B. digital rectal examinations. 

Coverage does not include: 

A. radical prostatectomy; 

B. external beam radiation therapy; 

C. radiation seed implants; or 

D. combined hormonal therapy. 

 6. Cervical Cancer Screenings - Coverage shall be provided for an annual cervical 

cancer screening test including a Pap test or any cervical cancer screening test 

approved by the FDA and recommended by a Doctor. 

 7. Cancer Screening Tests - Coverage shall be provided for generally medically accepted 

cancer screening tests. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 34 of 166
HCCL STMM 102 CA 15

8. Phenylketonuria (PKU) Treatment - Coverage shall be provided for the testing and 

treatment of phenylketonuria (PKU). Such coverage will include formulas and special 

food products that are: 

A. part of a diet prescribed by a Doctor; 

B. managed by a health care professional in consultation with a Doctor who 

specializes in the treatment of metabolic disease. 

Such diet must be Medically Necessary to avoid the development of a serious physical 

or mental disability; or to promote normal development or function as a consequence of 

PKU. Coverage is only required to the extent it exceeds the cost of a normal diet. 

As used here: 

"Formula" means an enteral product for use at home that is prescribed or ordered by a 

Doctor or other authorized health care provider as Medically Necessary for the treatment 

of PKU. 

"Special food products" means a food product that is both: 

A. prescribed by a Doctor for the treatment of PKU and consistent with the 

recommendations and best practices of qualified health professionals with 

expertise germane to, and experience in the treatment and care of, PKU. It does 

not include a food that is naturally low in protein, but may include a food product 

that is specially formulated to have less than one gram of protein per serving; 

and 

B. used in place of normal food products, such as grocery store foods , used by the 

general population. 

9. Osteoporosis - Coverage shall be provided for the diagnosis, treatment and appropriate 

management of osteoporosis. Coverage will include, but not be limited to, FDA 

approved technologies such as bone mass measurement, as deemed medically 

appropriate. 

10. Severe Mental Illness/Serious Emotional Disturbances of a Child - Coverage for 

Medically Necessary treatment shall be provided for: 

A. diagnosis and treatment of severe mental illness for a Covered Person of any 

age; and 

B. emotional disturbances of a child who: 

(a) has one or more mental disorders as identified in the most recent edition 

of the Diagnostic and Statistical Manual of Mental Disorders, other than a 

primary substance use disorder or developmental disorder, that result in 

behavior inappropriate to such child's age according to expected 

development norms; and 

(b) meets one or more of the following: 

(i) displays psychotic features, risk of suicide, or risk of violence due 

to a mental disorder; or 

(ii) meets special education eligibility requirements pursuant to 

California state law; or 

(iii) has substantial impairment, as a result of the mental disorder, in 

at least two of the following areas: self-care, school functioning, 

family relationships, or ability to function in the community and 

either of the following occur: the child is at risk of removal from 

his/her home or has already been removed from the home; or the 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 35 of 166
HCCL STMM 102 CA 16

mental disorder and impairments have been present for more than 

six months or are likely to continue for more than one year without 

treatment. 

Benefits shall include charges incurred for: 

1. Outpatient services; 

2. Inpatient hospital services, including inpatient prescription drugs and 

3. Partial hospital services. 

As used here: 

"Severe mental illness" shall include: 

1. Schizophrenia or schizoaffective disorder; or 

2. Bipolar disorder (manic-depressive illness); or 

3. Major depressive disorder; or 

4. Pa n ic d is o r d e r ; o r 

5. Obsessive-compulsive disorder; or 

6. Pervasive developmental disorder or autism; or 

7. Anorexia nervosa or bulimia nervosa. 

 11. Diabetes - Coverage shall be provided for Medically Necessary supplies, equipment and 

management and treatment of insulin using diabetes, non-insulin using diabetes and 

gestational diabetes. Coverage shall include: 

A. Blood glucose monitors, including glucose monitors for the visually impaired; 

B. Blood glucose test strips, ketone urine testing strips; 

C. Insulin pumps and related necessary supplies; 

D. Lancets and lancet puncture devices; 

E. pen delivery systems for the administration of insulin; 

F. Podiatric devices to prevent or treat diabetes related complications; 

G. I n s u l in s yr in g e s ; 

H. Visual aids (but not eyewear) to assist the visually impaired with proper dosing of 

insulin. 

Coverage shall also include outpatient self-management training, education and medical 

nutrition therapy services necessary to enable the Covered Person to properly use the 

equipment and supplies listed above. Such services must be provided by an 

appropriately licensed or registered health care professional as prescribed by a health 

care professional legally authorized to prescribe the services. 

 12. AIDS Vaccine – Coverage shall be provided for a vaccine for Acquired Immune 

Deficiency Syndrome (AIDS) that is approved by the FDA and recommended by the U.S. 

Public Health Service. 

 13. Cancer Clinical Trials - Coverage shall be provided for routine patient costs for a 

Covered Person diagnosed with cancer and accepted into a phase I, phase II, phase III, 

or phase IV clinical trial for cancer. The Covered Person’s Doctor must recommend 

participation in the clinical trial and determine that it will have a meaningful potential 

benefit. Treatment must be provided in a clinical trial that: 

A. involves a drug that is exempt under federal regulations from a new drug 

application; or 

B. is approved by one of the following: 

(a) one of the National Institutes of Health (NIH);

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 36 of 166
HCCL STMM 102 CA 17

(b) the FDA, in the form of an investigational new drug application; 

(c) the U.S. Department of Defense; or 

(d) the U.S. Veterans’ Administration. 

“Routine patient costs” means costs associated with the provision of health care 

services, including drugs, items, devices, and services that would otherwise be covered 

under the plan or contract if those drugs, items, devices, and services were not provided 

in connection with an approved clinical trial program, including the following: 

A. Health care services typically provided absent a clinical trial. 

B. Health care services required solely for the provision of the investigational drug, 

item, device, or service. 

C. Health care services required for the clinically appropriate monitoring of the 

investigational item or service. 

D. Health care services provided for the prevention of complications arising from the 

provision of the investigational drug, item, device, or service. 

E. Health care services needed for the reasonable and necessary care arising from 

the provision of the investigational drug, item, device, or service, including the 

diagnosis or treatment of the complications. 

It does not include: 

A. drugs or devices not approved by the FDA and that are associated with the clinical 

trial; 

B. services other than health care services, such as travel, housing, companion 

expenses and other nonclinical expenses; 

C. any item or service that is provided solely to satisfy data collection and analysis 

needs and that is not used in the clinical management of the patient. 

D. health care services which, except for the fact that they are not being provided in a 

clinical trial, are otherwise specifically excluded under this certificate; or 

E. health care services customarily provided by the research sponsors free of charge 

for any enrollee in the trial. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 37 of 166
HCCL STMM 102 CA 18

PART VI – EXCLUSIONS 

Charges for the following treatments and/or services and/or supplies and/or conditions are 

excluded from coverage: 

 1. Pre-existing Conditions – Charges resulting directly or indirectly from a condition for 

which a Covered Person received medical treatment, diagnosis, care or advice within 

the six (6) month period immediately preceding such person’s Effective Date are 

excluded for the first six (6) months of coverage hereunder. A Covered Person who 

was covered under creditable coverage within 63 days of enrolling under this certificate 

shall be given credit for the period of time under such coverage toward the satisfaction 

of this exclusion. This exclusion does not apply to a newborn or newly adopted child 

who is added to coverage under this certificate in accordance with PART II – 

ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE. Creditable Coverage means 

any of the following: 

A. A g rou p h ea lth p lan; or 

B. Health insurance coverage (care under any hospital or medical service policy or 

certificate; hospital or medical service plan contract; or Health Maintenance 

Organization (HMO); or 

C. In d ividua l co verag e; or 

D. M e d i c a r e ; o r 

E. M e d i c a i d ; o r 

F. C H A M P U S ; o r 

G. A medical care program of the Indian Health Service or of a tribal organization; 

or 

H. A State health benefits risk pool; or 

I. A health plan offered under the Federal Employees Health Benefits Program 

(FEHBP); or 

J. A public health plan; or 

K. A health benefit plan under the Peace Corps Act.

Creditable coverage does not include accident only, credit, coverage for onsite medical 

clinics, disability income, Medicare supplement, long-term care insurance, dental, 

vision, coverage issued as a supplement to liability insurance, workers’ compensation 

insurance or similar law, automobile medical payment insurance, or insurance under 

which benefits are payable with or without regard to fault and that is statutorily required 

to be contained in any liability insurance policy or equivalent self-insurance. 

Any coverage under which an insured was covered prior to a break in coverage of 63 

consecutive days or more, not counting any waiting period or affiliation period required 

by any Creditable Coverage, will not be considered Creditable Coverage. 

 2. Outpatient Prescription Drugs, medications, vitamins, and mineral or food supplements 

including pre-natal vitamins, or any over-the-counter medicines, whether or not ordered 

by a Doctor. 

 3. Routine pre-natal care, Pregnancy, childbirth, and postnatal care. (This exclusion does 

not apply to “Complications of Pregnancy” as defined.) 

 4. Alcoholism. 

 5. Substance abuse. 

 6. Charges which are not incurred by a Covered Person during his/her Coverage Period. 

 7. Treatment, services or supplies, which are not administered by or under the supervision 

of a Doctor. 

 8. Treatment, services or supplies which are not Medically Necessary as defined. 

 9. Treatment, services or supplies provided at no cost to the Covered Person. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 38 of 166
HCCL STMM 102 CA 19

10. Charges which exceed Usual and Customary charge as defined. 

11. Telephone consultations or failure to keep a scheduled appointment. 

12. Consultations and/or treatment provided over the Internet. 

13. Surgeries, treatments, services or supplies which are deemed to be Experimental 

Treatment. 

14. All charges Incurred while confined primarily to receive Custodial or Convalescence 

Care. 

15. Weight modification or surgical treatment of obesity, including wiring of the teeth and all 

forms of intestinal bypass surgery. 

16. Modifications of the physical body in order to improve the psychological, mental or 

emotional well-being of the Covered Person, such as sex-change surgery. 

17. Surgeries, treatments, services or supplies for cosmetic or aesthetic reasons, except for 

reconstructive surgery which is expressly covered under this certificate. 

18. Any drug, treatment or procedure that either promotes or prevents conception including 

but not limited to: artificial insemination, treatment for infertility or impotency, 

sterilization or reversal of sterilization. 

19. Any drug, treatment or procedure that either promotes, enhances or corrects impotency 

or sexual dysfunction. 

20. Abortions, except in connection with covered Complications of Pregnancy or if the life of 

the expectant mother would be at risk. 

21. Dental treatment, except for dental treatment that is expressly covered under this 

certificate. 

22. Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual 

therapy, and any examination or fitting related to these devices, and all vision and 

hearing tests and examinations. 

23. Eye surgery, such as radial keratotomy, when the primary purpose is to correct 

nearsightedness, farsightedness or astigmatism. 

24. Treatment for cataracts. 

25. Treatment of the temporomandibular joint, except for medically necessary surgical 

procedures for covered conditions directly affecting the upper or lower jawbone or 

associated bone joints. 

26. Injuries resulting from participation in any form of skydiving, scuba diving, auto racing, 

bungee jumping, hang or ultra light gliding, parasailing, sail planing, flying in an aircraft 

(other than as a passenger on a commercial airline), rodeo contests or as a result of 

participating in any professional, semi-professional or other non-recreational sports 

including boating, motorcycling, skiing, riding all-terrain vehicles or dirt-bikes, 

snowmobiling or go-carting. 

27. Injuries or Sicknesses resulting from participation in interscholastic, intercollegiate or 

organized competitive sports. 

28. Injury resulting from being under the influence of or due wholly or partly to the effects of 

alcohol or drugs, other than drugs taken in accordance with treatment prescribed by a 

Doctor, but not for the treatment of Substance Abuse. 

29. Willfully self-inflicted Injury or Sickness. 

30. Immunizations and Routine Physical Exams, except as expressly covered under this 

certificate or under a Rider attached to this certificate. 

31. Services received for any condition caused by a Covered Person’s commission of or 

attempt to commit a felony or to which a contributing cause was the Covered Person 

being engaged in an illegal occupation. 

32. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or 

music therapy, holistic care of any nature, massage and kinestherapy. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 39 of 166
HCCL STMM 102 CA 20

33. Any services performed or supplies provided by a member of the Insured’s Immediate 

Family. 

34. Orthoptics and visual eye training. 

35. Services or supplies which are not included as Eligible Expenses as described herein. 

36. Care, treatment or supplies for the feet: orthopedic shoes, orthopedic prescription 

devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable 

or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or 

toenails. 

37. Care and treatment for hair loss including wigs, hair transplants or any drug that 

promises hair growth, whether or not prescribed by a Doctor. 

38. Treatment of sleep disorders. 

39. Hypnotherapy when used to treat conditions that are not recognized as Mental or 

Nervous Disorders by the American Psychiatric Association, and biofeedback, and nonmedical self-care or self-help programs. 

40. Any services or supplies in connection with cigarette smoking cessation. 

41. Exercise programs, whether or not prescribed or recommended by a Doctor. 

42. Treatment required as a result of complications or consequences of a treatment or 

condition not covered under this certificate. 

43. Charges for travel or accommodations, except as expressly provided for local 

ambulance. 

44. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or 

radioactive material(s). 

45. Organ or Tissue Transplants or related services. 

46. Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea, 

sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic 

conditions of skin, nevus. 

47. Services received or supplies purchased outside the United States, its territories or 

possessions, or Canada. 

48. Treatment for or related to any congenital condition, except as it relates to a newborn or 

adopted child added as a Covered Person to this certificate. 

49. Spinal manipulation or adjustment. 

50. Sclerotherapy for veins of the extremities. 

51. Expenses during the first 6 months after the Effective Date of coverage for a Covered 

Person for the following (subject to all other coverage provisions, including but not 

limited to the Pre-existing Condition exclusion): 

A. Total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis 

of carcinoma; 

B . T o n s i l l e c t o m y ; 

C . A d e n o i d e c t o m y ; 

D. Repair of deviated nasal septum or any type of surgery involving the sinus; 

E . M y r i n g o t o m y ; 

F . T y m p a n o t o m y ; 

G . H e r n i o r r h a p h y ; o r 

H. Ch o le c y s t e c t o m y. 

52. Chronic fatigue or pain disorders. 

53. Treatment or diagnosis of allergies, except for emergency treatment of allergic reactions. 

54. Treatment, medication or hormones to stimulate growth, or treatment of learning 

disorders, disabilities, developmental delays or deficiencies, including therapy. 

55. Kidney or end stage renal disease. 

56. Joint replacement or other treatment of joints, spine, bones or connective tissue 

including tendons, ligaments and cartilage, unless related to a covered Injury. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 40 of 166
HCCL STMM 102 CA 21

57. Expenses resulting from a declared or undeclared war, or from voluntary participation in 

a riot or insurrection. 

58. Expenses incurred by a Covered Person while on active duty in the armed forces. Upon 

written notice to Us of entry into such active duty, the unused premium will be returned 

to the Covered Person on a pro-rated basis. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 41 of 166
HCCL STMM 102 CA 22

PART VII – COORDINATION OF BENEFITS (COB) 

Some people have health care coverage through more than one medical insurance plan at the 

same time. COB allows these plans to work together so the total amount of all benefits will 

never be more than 100 percent of the allowable expenses during any coverage year. This 

helps to hold down the costs of health coverage. 

COB does not apply to life insurance or accidental death and dismemberment benefits. 

The term “plan” applies separately to each policy, contract agreement or other arrangements for 

benefits or services. The term “plan” also applies separately to that part of any policy, contract, 

agreement or other arrangements for benefits or services that coordinates its benefits with other 

plans and to that part that does not. 

When a plan provides benefits in the form of services rather than cash payment the reasonable 

cash value of each service rendered will be considered to be both: (1) an allowable expense; 

and (2) a benefit paid. 

Definitions. “Plan” – means any of the following which provides benefits or services for 

medical expenses: 

1. Any group insurance or group-type coverage, whether insured or uninsured. This 

includes prepayment, group practice, or individual practice coverage. 

2. Any federal, state or local governmental programs, or coverage required or provided by 

law. This does not include a state plan under Medicaid (Title XIX, Grants to States for 

Medical Assistance Programs, of the United States Social Security Act, as amended 

from time to time.) 

Each contract or other arrangement for coverage under the above paragraphs is a separate 

plan. Also, if an arrangement has two parts and COB rules apply to one of the two, each of the 

parts is construed to mean a separate Plan. 

The term "plan" does not include: 

1. Individual or family insurance or subscriber contracts; 

2 Individual or family coverage through Health Maintenance Organizations (HMOs); 

3. Individual or family coverage under other prepayment, group practice and individual 

practice plans; 

4. School accident-type coverages. (These contracts cover students for accidents only, 

including athletic injuries, either on a twenty-four hour basis or on a to-and-from school 

basis); 

5. Group or group-type hospital indemnity benefits of $100 per day or less; 

6. Medicare Supplement policies; 

7. A state plan under Medicaid. 

“Primary Plan (Primary)” – means the Plan which determines its benefits before those of the 

other Plan. When there are more than two (2) Plans, This Plan may be Primary as to one and 

Secondary as to another. 

“Secondary Plan (Secondary)” – means the Plan which determines its benefits after those of 

the other Plan. When there are more than 2 Plans, This Plan may be Secondary as to one and 

Primary as to another. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 42 of 166
HCCL STMM 102 CA 23

“This Plan” – means the benefits provided under this group policy. 

Effect on Benefits. Plans use COB to decide which plan should pay first for a covered 

expense. If the Primary Plan’s payment is less than the charge for the allowable expense, then 

the Secondary Plan will apply its benefit payment to the balance. 

The following rules will be used to establish the order of benefit determination: 

 1. A plan which does not have a COB provision will always be the Primary Plan. 

 2. The benefits of a plan which covers the person on whose expenses the claim is based 

as other than a dependent will be determined before the benefits of a plan which covers 

the person as a dependent. However, if the person is also a Medicare beneficiary, and if 

the rule established under the Social Security Act of 1965, as amended, makes 

Medicare secondary to the plan covering the person as a dependent of an active 

employee, the order of benefit determination is: 

A. First, benefits of a plan covering persons as an employee, member, or 

subscriber. 

B. Second, benefits of a plan of an active worker covering persons as a dependent. 

C. Third, Medicare benefits. 

 3. The benefits of a plan that covers a person for whom a claim is made as a dependent 

child will be determined under the following rules:

A. When the parents are married: the benefits of a plan which covers the child as a 

dependent of the parent whose birthday anniversary occurs earlier in the 

calendar year will be determined before the benefits of a plan which covers the 

child as a dependent of the parent whose birthday anniversary occurs later in the 

calendar year. 

B. If both parents have the same birthday the benefits of the plan that covered the 

parent longer are determined before those of the plan that covered the other 

parent for a shorter period of time. 

C. If the plans do not agree on the order of benefit rules because the other plan 

does not have the rule described in this section, but has a rule based upon the 

gender of the parent, the rule in the other plan will determine the order of 

benefits. 

D. When the parents are separated or divorced and the parent with custody has not 

remarried the benefits of a plan which covers the child as a dependent of the 

parent with custody of the child will be determined before the benefits of a plan 

which covers the child as a dependent of the parent without custody. 

E. When the parents are divorced and the parent who has custody of the child has 

remarried: (a) the benefits of a plan which covers the child as a dependent of the 

parent with custody will be determined before the benefits of a plan which covers 

the child as a dependent of the step-parent; and (b) the benefits of a plan that 

covers the child as a dependent of the step-parent will be determined before the 

benefits of a plan that covers the child as a dependent of the parent without 

custody. 

F. Despite (2) and (3) above, if there is a court decree which would otherwise 

establish financial responsibility for the medical, dental or other health care 

expenses with respect to the child, the benefit payment of a plan which covers 

the child as a dependent of the parent with such financial responsibility will be 

determined before the benefit payment of any other plan that covers the child as 

a dependent child. 

 4. The benefits of a plan that covers a person as a primary insured who is neither laid off 

nor retired, or as that primary insured’s dependent, are determined before those of a 

plan that covers that person as a laid off or retired primary insured or as that primary 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 43 of 166
HCCL STMM 102 CA 24

insured’s dependent. This rule will not apply if the other plan does not have this rule and 

if, as a result, the plans do not agree on the order of benefits. 

5. If a person whose coverage is provided under a right of continuation pursuant to federal 

or state law is covered under another plan, the following will be the order of benefit 

determination: 

A. First, the benefits of a plan covering the person as an employee, member, or 

subscriber (or as that person’s dependent); 

B. Second, the benefits under the continuation coverage. If the other plan does not 

have the rule described above and if, as a result, the plans do not agree on the 

order of benefits, this rule is ignored. 

6. When rules 2 through 5 do not establish an order of benefit determination the benefits of 

a plan which has covered the person on whose expenses the claim is based for the 

longer period of time will be determined before the benefits of a plan which has covered 

the person the shorter period of time. 

Facility of Payment. If another plan makes a benefit payment that should have been made by 

us we have the right to pay the other plan any amount we deem necessary to satisfy our 

obligation under these COB rules. 

Right of Recovery. If the amount of our benefit payment is more than the amount needed to 

satisfy our obligation under these COB rules, we have the right to recover the excess amount 

from: (A) any persons to or for whom, or with respect to whom, the payments were made; (B) 

any insurance companies; or (C) any other organizations. 

Right to Receive and Release Necessary Information. In order to carry out these COB rules: 

1. We have the right, without the consent of or notice to any person, to exchange 

information with any person, insurance company or organization, as we deem 

necessary; and 

2. Any person claiming benefits under this plan must give us any information necessary to 

carry out this provision. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 44 of 166
HCCL STMM 102 CA 25

PART VIII - CLAIM PROVISIONS 

Notice of Claim: Written notice of claim must be given within 31 days after a covered loss 

begins or as soon as is reasonably possible. The notice must be given to the Company named 

on the Schedule of Benefits. Notice should include information that identifies the claimant and 

the policy. 

Claim Forms: When the Company receives notice of claim, forms for filing proof of loss will be 

sent to the claimant. If claim forms are not supplied within 15 days, a claimant can give proof as 

follows: 

1 . I n w r i t i n g ; 

2 . Setting forth the nature and extent of the loss; and 

3 . Within the time stated in the Proof of Loss provision. 

Proof of Loss: Written proof of loss must be given to the Company within 90 days after the loss 

begins. We will not deny nor reduce any claim if it was not reasonably possible to give proof of 

loss in the time required. In any event, proof must be given to the Company within one year 

after it is due unless the Insured is legally incapable of doing so. 

Time of Payment of Claim: Benefits for loss covered by the policy will be paid as soon as we 

receive proper written proof of such loss, but no later than 30 working days after We receive 

Proof of Loss. 

Payment of Claims: All benefits will be paid to the Insured, if living, unless an Assignment of 

Benefits has been requested by the Insured. Any other benefits due and unpaid at the Insured’s 

death will be paid to the Insured’s estate. If a benefit is to be paid to the Insured’s estate, or to 

an Insured or beneficiary who is not competent to give a valid release, the Company may pay 

up to $1,000.00 of such benefit to one of the Insured’s relatives who is deemed by the Company 

to be justly entitled to it. Such payment, made in good faith, fully discharges the Company to 

the extent of the payment. 

Physical Examination: At our expense, we may have a person claiming benefits examined as 

often as reasonably necessary while the claim is pending. 

Legal Action: No legal action may be brought to recover on the policy before 60 days after 

written proof of loss has been furnished as required by the policy. No such action may be 

brought after three years from the time written proof of loss is required to be furnished. 

Third Party Liability: No benefits are payable for any Sickness, Injury, or other condition for which 

a third party may be liable or legally responsible by reason of negligence, an intentional act, or 

breach of any legal obligation on the part of such third party. Nevertheless, the Company will 

advance the benefits of this policy to the Insured subject to the following: 

1. The Insured agrees to advise Us, in writing, within 60 days of any Covered Person’s 

claim against the third party and to take such action, provide such information and 

assistance, and execute such paper as We may require to facilitate enforcement of the 

claim. The Insured and Covered Person also agree to take no action that may prejudice 

Our rights or interests under this policy. Failure to provide notice of a claim or to 

cooperate with Us, or actions that prejudice Our rights or interests, will be material 

breach of this policy and will result in the Insured being personally responsible for 

reimbursing Us. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 45 of 166
HCCL STMM 102 CA 26

2. We will automatically have a lien, to the extent of benefits advanced, upon any recovery 

that any Covered Person receives from the third party, the third party’s insurer, or the 

third party’s guarantor. Recovery may be by settlement, judgment or otherwise. The 

lien will be in the amount of benefits paid by Us under this policy for the treatment of the 

Sickness, disease, Injury or condition for which the third party is liable. 

Independent Medical Review: A Covered Person, or a representative acting on his or her 

behalf, has the right to request an independent medical review whenever healthcare services 

have been denied, modified or delayed by Us, if the decision was based in whole or in part on a 

finding that the proposed health care services are not medically necessary. A doctor, or other 

health care provider, may assist in seeking an independent medical review and may advocate 

on such Covered Person's behalf. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 46 of 166
HCCL STMM 102 CA 27

PART IX – GENERAL PROVISIONS 

Time Limit on Certain Defenses: The validity of coverage issued under the Policy with respect 

to an Insured or his Eligible Dependents may not be contested after three years from each 

certificate’s effective date, except for nonpayment of premiums. 

Misstatement of Age: If the age of any Covered Person is incorrectly stated, we will make a fair 

adjustment of the premiums, benefits or both. The adjustment will be based on the premiums 

and benefits that would have been payable had we known the correct information. 

Not in Lieu of Workers’ Compensation: The policy is not in lieu of and does not affect 

requirements for coverage under Workers’ Compensation laws. 

Pronouns: Whenever a personal pronoun in the masculine gender is used, it will be deemed to 

include the feminine also, unless the context clearly indicates to the contrary. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 47 of 166
HCCL STMM 102 CA 28

PART X – SCHEDULE OF BENEFITS 

INSURED INFORMATION: 

Name: 

Policy Effective Date: 

COVERAGE PERIOD: 

ELIGIBILE DEPENDENTS COVERED

COVERAGE AND BENEFIT AMOUNTS: 

Deductible per Covered Person per 

Coverage Period. Maximum of 3 

Deductibles per family per Coverage 

Period. 

An additional Deductible of $250 per visit 

will be applied to charges for use of 

emergency room in the event of Sickness 

unless the Covered Person is directly 

admitted as an Inpatient for further 

treatment. 

Coinsurance During a Coverage Period, the Company 

will pay of the next $5,000 of 

Eligible Expenses after the Deductible, 

then 100% of Eligible Expenses to the 

Overall Maximum Limit. 

Urgent Care Center For each visit, the Covered Person shall be 

responsible for a $50 co-payment, after 

which Coinsurance will apply. Not subject 

to Deductible 

Hospital Room and Board Average Semi-private room rate, including 

nursing services.

Local Ambulance Injury: Usual and Customary charges to a

Maximum of $250 per trip, when related to 

a covered Injury. 

Sickness: Usual and Customary charges to 

a maximum of $250 per trip, when covered 

Sickness results in hospitalization as 

Inpatient 

Intensive Care Unit Usual and Customary charges 

Physical Therapy $50 Maximum per visit per day 

Home Health Care Maximum 1 visit per day. Maximum of 40 

visits during a Coverage Period 

Extended Care Facility Not to exceed a daily rate of $150 nor a 

maximum of 60 days 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 48 of 166
HCCL STMM 102 CA 29

All Other Eligible Medical Expenses Usual and Customary charges 

Penalty for Failure to Pre-certify 50% of Eligible Medical Expenses 

Overall Maximum Limit per Coverage 

Period 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 49 of 166
EXHIBIT 8 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 50 of 166
Exhibit 8 

HOME PRODUCTS • CUSTOMER SERVICE • PRODUCERS • SLOG 

California Short Term Medical Insurance Plans Our 1ntemi'ltiot\lll prov•cler network mdud~ over- 370,000 hei'l!th <~re 

the network 

I'@Sid@ll{$ 

need!ng health ca•·e covecage. Tempora.y health lnsuraoce plans are availabieo in a range of 

deductibles and do not require a p•tmary cal\'! ph'(Sidan. In Catlfomia. reSi~ t covesage 

itw:ludes screMing> and other J)lf!\•entative C¥e. Short term m edical insurKtce plans In 

Califomia also indude c.hil~specltic services. 

General STM Benefits 

Deductible 01Qiices· $500, !>l,OOO, $'2:,500. sS,OOO ¥ld s7,SOO 

No Rerenals t."eeoea ror SP«iallSts ExctP( Physical th«apy 

No PrlmafY cz.·e Physician fl.eQultea 

Out·of4 Networ'l< coveraoe 

ChOICe or 80/20% Of SO/SO% COtOSOfance 

Covefage M<numum up to Sl,OOO,OOO ure.:rme 

Hospital inp<~tleot Presulptlo•l Drug coverage 

Lab/X-ray, Emergency Room, Outpatient SUrg@l)' & Hospitalization co .. erage 

California-Specific STM Benefits 

Periodic M<\ mogr~m x~:~ms Beg•nntng t Age: 3S 

Cc:rvKol C<1ncc:r Screc:rungs lndud..,g P;)p Te$t 

Chid r~venti'lt•ve C<1re and Chidhood JmmUillli't•ons up to ;.,gc 16 

ent"l Hc:ollth Cove•·.,oe 

Dental Anesthesia 

Cover~oe f« 14ecllea!ly Ne¢et£ary Pr<>ttMtlc C>evlcet After Uryr\QeC~()IYiy Go roe-tv Prost<Ke Sc•eenulOS 

Osttoporosis Management all(l Treatment 

Diabetes. St4)plles 

AIDS V&ednation 

cance-r Clfnical T•1als 

Treaament for the Ph~nylketonurl.a Birth Defect 

cancer screening Te ~ 

Limits and Considerations of STM Coverage 

Cover.:'IOC: for- l to 6 months 

Pre·e>ciSOOO e<~nclltions exclu<Jeo 

SHORT TERM MEDICAL 

Short t erm he.afth inst.rance for 

tempor&ry gaps in <:oV"erage. 

lEARN MORE 

or 

G"l a Quot~ 

72 llour wt'lltlno oerio<l ror illness wneo coveraoe Is l).lr<tlase<J 'W tllin ouee Clays or cne -effect•ve <1Jte. •NalUOO perioa Cloes not 

aoctv to lf\lu•1es. 

For in(llvl(fual heaiiD •nsur.:tfl<e purcnaslno oui<Jes an<J suooestiOf'IS, see the Callromla De1>anment or tnsuraoce Resoun:e: 

www .lns.urance. ca .gov 

There .are transitional pertods In life that can leave you Without medical cow-rage for a b1tef time. HCC fotedicaltosura llCe Services 

understands vour need ior peace of mind abeta. health insurance cove.-age during unce11aio s. 

Get Short Te1 m Insurance 

RESOURCES 

tmpoetant tofo..nauon 

Privacy Polley 

Te-ms of use 

Leoa1 Notice 

ABOUT US 

About Tokb Marir'h;o HCC MIS Gr-oup 

Contact Us 

Site Map 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 51 of 166
EXHIBIT 9 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 52 of 166
Exhibit 9

Step One:

Step Two: 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 53 of 166
Step Three:

Step Four:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 54 of 166
Step Five:

Step Six:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 55 of 166
Step Seven:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 56 of 166
EXHIBIT 10 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 57 of 166
Exhibit 10

Step One:

Step Two:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 58 of 166
Step Three:

Step Four:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 59 of 166
Step Five:

Step Six:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 60 of 166
Step Seven:

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 61 of 166
EXHIBIT 11 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 62 of 166
HCC Life Insurance Company

HCC Life Short Term Medical

Transition

between Job

New Employees Waiti

Medicare Cover

recent gradua

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 63 of 166
Why Choose HCC Life Short Term Medical?

HCC Life Short Term Medical (STM) provides affordable 

temporary health insurance to protect you and your family. 

You should consider purchasing HCC Life STM if you are 

concerned about protecting yourself from the potentially 

high medical costs associated with an unexpected sickness 

or injury.

With HCC Life Short Term Medical you are in control. You 

get to choose your deductible, coinsurance, maximum 

coverage amount, and the exact length of coverage. You 

also have the freedom to receive treatment from doctors 

and hospitals of your choice without incurring out of 

network penalties. HCC Life Short Term Medical gives you 

peace of mind.

For more information about HCC Life Short Term Medica

please visit hccmis.com

After purchasing coverage, how can I trust the

company to be there if I need them?

For more than 30 years, HCC Life Insurance Company has 

been leading the way in medical stop loss insurance for 

employers who self-fund their employee benefit plans. 

HCC Life’s products, including medical stop loss, HMO 

reinsurance, medical excess, group term life insurance and 

short term medical insurance are backed by the financial 

stability of its parent company, HCC Insurance Holdings, 

Inc. (NYSE: HCC). HCC Life holds a financial strength 

rating of AA (Very Strong) by Standard & Poor’s and Fitch 

Ratings and A+ (Superior) by A.M Best Company.

Waiting for major medical Cobra substitute Recently naturalized U.S. citizens

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 64 of 166
Benefits of HCC Life Short Term Medical

Length of Coverage Up to 6 or 11 months. Purchase in full or make monthly payments.

Deductibles $250, $500, $1000, $25,00, $5000, or $750

A maximum of 3 deductibles is required per family

Coinsurance 80% or 50% of the next $5,000 of eligible medical expenses

Coverage Period Maximum $1 million or $2 milli

How HCC Life Short Term Medical Wo

Policy benefits are subject to the deductible and 

coinsurance. After you satisfy your deductible, HCC Life 

STM will begin paying eligible expenses according to the 

coinsurance you select and up to the coverage period 

maximum that you choose. Benefits are based on usual 

and customary charges of the geographical area in which 

charges are incurred.

Urgent Care Cente

The deductible is waived when you receive care at an 

urgent care center, and instead you pay a $50 co-payment, 

after which coinsurance applies. An urgent care center 

means a facility separate from a hospital emergency 

department where patients can be immediately treated 

for injury or sickness on a walk-in basis without an 

appointment. 

HCC Life Short Term Medical Cover

•	Inpatient and outpatient charges made by a hospital, 

including inpatient prescription drugs

•	Charges incurred at an urgent care center after 

a $50 co-pay

•	Charges made by a physician, surgeon, radiologist, 

anesthesiologist, and any other medical specialist to 

whom the physician has referred the case

•	Charges made for dressings, sutures, casts or 

other supplies prescribed by the attending physician 

or specialist, but excluding nebulizers, oxygen tanks, 

diabetic supplies and all devices for repeat use at home

•	Charges for diagnostic testing using radiology 

ultrasonographic or laboratory services

•	Charges for oxygen and other gases and anesthetics and 

their administration

•	Charges made by a licensed extended care facility upon 

direct transfer from an acute care hospital

•	Emergency local ambulance transport in connection 

with injury or sickness resulting in inpatient 

hospitalization

•	Expenses related to complications of pregnancy

•	Charges for physical therapy that is prescribed in 

advance by a physician in relation to a covered injury 

or sickness

The description of coverage in these pages is for informational purposes only. Actual 

coverage will vary based the terms and conditions of the policy issued. The information described herein does not amend or otherwise affect the terms and conditions 

of any insurance policy issued by HCC Life Insurance Company or its affiliates. In 

the event that a policy is inconsistent with the information described herein, the 

language of the policy will take precedence. Please see the policy for detailed information about these and other policy exclusions and limitations. Benefits, provisions, 

limitations and exclusions may vary by state.

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 65 of 166
Eligibility and Enrollment 

for HCC Life Short Term Medical

Coverage Effective Da

For enrollment forms received online, by e-mail, or by fax, 

your coverage becomes effective at 12:01 a.m.* on the date 

following the date we receive your completed application 

form provided payment has been received. For application 

forms submitted by mail, your effective date is 12:01 a.m.* 

on the postmark date of your completed application form 

or 12:01 a.m.* on the requested effective date, whichever is 

later, provided payment has been received. Your requested 

effective date must be within 45 days from the date you 

signed the application form.*

*Times expressed are based on the geographical area where the policy holder resides.

HCC Life STM Eligibilit

You are eligible to apply for HCC Life STM if you are age 2 

through 64 and you meet the following requirements:

1. You are not pregnant, an expectant father, or planning 

on adopting.

2. You will not be covered by other medical insurance at 

time of requested effective date.

3. You are not a member of the armed forces of any 

country, state, or international organization, other than 

on reserve duty for 30 days or less; and 

4. You are able to answer “no” to the medical questions on 

the application form.

**Your spouse under age 65 and dependents under age 19 are also eligible for coverage, provided they meet the same requirements. Unmarried children under age 25 

may also be included as a covered dependent if enrolled full-time in an accredited 

school or college. Eligibility for children ages 19 through 25 may vary by state. In 

order to receive coverage, applicant may be required to enroll in the Consumer 

Benefits of America Association.

Purchasing HCC Life Short Term Medi

HCC Life STM is offered through a nationwide network 

of independent insurance agents contracted with HCC 

Medical Insurance Services (HCCMIS). To purchase 

HCC Life STM, an application form must be completed. 

Application forms may be submitted via mail, fax or online. 

If you apply online, your initial payment must be made 

by credit card (Visa, American Express, Discover or 

MasterCard). If application is by mail, you may submit 

premium via personal check or credit card. Payment 

options include single up-front or monthly payments. 

Purchasing an Additional Pol

HCC Life STM is not renewable, but if your temporary 

insurance need continues beyond the coverage period 

purchased, you may apply for a new policy as long as 

you have not had more than two HCC Life STM policies 

during the past 12 months. Additional purchase may not be 

available in some states.

Free Look Peri

If you are not 100% satisfied with HCC Life STM, return the 

certificate along with a written request for cancellation 

to HCC Life within 10 days of receipt. Coverage will be 

cancelled as of the effective date. No questions asked! 

Consumer Benefits of Ameri

In most states, HCC Life STM is available to members of the 

Consumer Benefits of America Association. Membership in 

the association will entitle you to discounts of up to 40% 

off regular retail prices on many short-term and longterm prescription drugs. Discounts are available from over 

59,000 participating pharmacy providers nationwide or 

by mail service. When membership is required, association 

fees are assessed at the time of application; enrollment in 

the association is automatic upon payment of the correct 

premium and all applicable

HCC Life Insurance Company respects individual privacy and values the confidence 

of its customers, employees, consumers, business associates, and others. Please 

contact us or visit our website to obtain a full version of our Privacy Policy.

HCC Life Insurance Company 251 North Illinois Street, Suite 600, Indianapolis, IN 46204 main (800) 605 2282 facsimile (317) 262 2140 hccmis.com

A subsidiary of HCC Insurance Holdings, Inc. hcc.com

5000-STM-628-8966

Not all coverages or products may be available in all jurisdictions. The description of coverage in these pages is for information purposes only. 

Actual coverages will vary based on local law requirements and the terms and conditions of the policy issued. The information described herein does 

not amend, or otherwise affect, the terms and conditions of any insurance policy issued by HCC.

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 66 of 166
EXHIBIT 12 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 67 of 166
Medical Questions 

Please answer the questions below as they apply to the Applicant (Primary person listed 

above) applying for coverage. For each family member applying for coverage, complete and 

answer the questions on the Dependent Medical Questionnaire.

1. Will you have other health insurance in force on the policy effective date or be eligible for Medicaid? Yes No 

2. Have you: 

a. Been denied insurance due to any health reasons for a condition that is still present? 

b. Now pregnant, in process of adoption or undergoing infertility treatment? 

c. Over 300 pounds if male or over 250 pounds if female? 

 Yes No 

3. Within the last 5 years have you been diagnosed, treated, or taken medication for any of the following: 

cancer or tumor, stroke, heart disease including heart attack, chest pain or had heart surgery, COPD 

(chronic obstructive pulmonary disease) or emphysema, Crohn's disease, liver disorder, degenerative 

disc disease or herniation/bulge, rheumatoid arthritis, kidney disorder, diabetes, degenerative joint 

disease of the knee, alcohol abuse or chemical dependency, or any neurological disorder? 

 Yes No 

4. Within the last 5 years have you been diagnosed or treated by a physician or medical practitioner for 

Acquired Immune Deficiency Syndrome (AIDS)? 

 Yes No 

5. If you are not a US Citizen, do you expect to legally reside in the US for the duration of the policy? Yes No 

 US citizen 

If you have answered “Yes” to questions 1 through 4 or “No” to question 5 above, coverage cannot be issued. 

Thank you for your interest. 

California law prohibits an HIV test from being required or used by health insurance companies as a condition of 

obtaining health insurance coverage. 

HCC Life STM 

Enrollment Form 

For use in CA

Personal Details Please provide the following details for all individuals to be covered. 

Name (First and Last) Date of Birth Gender Contact Information 

Primary Male 

 Female 

Address 

Spouse Male 

 Female 

City State Zip 

Child 1 Male 

 Female 

Phone Number 

Child 2 Male 

 Female 

E-mail Address 

• Please complete this application entirely. Failure to provide 

complete information may delay processing. 

• You may elect the $5,000 and $7,500 deductible options by 

applying online or contacting us. 

Plan Options 

Please check the boxes corresponding to 

your elections for deductible and 

coinsurance.

Payment 

Option Monthly – 6 month plan 

Deductible $250 $500 $1,000 $2,500 $5,000 $7,500 Single Up Front (please specify term date)

Coinsurance 80% of $5,000 50% of $5,000 Specify Term Date ________________ 

Requested Effective Date _____/ ______ / _________ Number of days (max 180) _________

Please submit completed applications with 

payment to: 

HCC Life Insurance Company 

251 N. Illinois Street, Suite 600 

Indianapolis, IN 46204 

For product information or assistance with 

this enrollment form, please contact: 

 

HCCL STMM ENR CA (01/09) 

(Herein referred to as HCC Life)

2015 01-14- ✔

12 ✔

✔

✔

✔

✔

✔

✔

09 MOHOMMED AZAD ✔

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 68 of 166
Payment Information 

Please provide complete payment information. 

Applications without payment cannot be processed. 

Check/Money Order (Single Up-Front Payment 

Only) MasterCard VISA 

 Discover American Express

Credit Card Number Exp Date 

Name on Card 

Phone # 

Billing Address (including city, state and zip) 

Check or Money Orders should be made payable, in 

US dollars, to HCC Life Insurance Company. If 

paying by credit card, I authorize HCC Life to debit 

my Discover, VISA, MasterCard or American 

Express account for the amount specified in the 

Rate Calculation section. If I have selected a 

monthly plan, I hereby request and authorize HCC 

Life to debit my Credit Card account for the proper 

installment amounts on the due dates of the 

installments. This authorization will remain in effect 

for the duration of the Coverage Period elected or 

until revoked by me in writing. Coverage purchased 

by credit card is subject to validation and 

acceptance by the credit card company. 

Cardholder Signature Date 

Authorization 

I hereby request coverage under the insurance issued to the Consumer Benefits of America Association and underwritten by 

HCC Life Insurance Company. I understand this insurance contains a Pre-existing Condition exclusion, a Pre-certification 

Penalty and other restrictions and exclusions. I agree that coverage will not become effective for me or any dependent whose 

medical status, prior to the effective date, has changed and therefore results in a “yes” answer to any of the medical questions 

on this application. If my medical status changes in this way, coverage will be declined for all individuals included on this 

application. I understand that if I have elected the Monthly Payment option, my credit card will be charged each month on the 

due date of the premium for 6 months, depending on the plan I have selected. I understand that I may terminate the scheduled 

payments by notifying HCC Life in writing at least one business day prior to the next scheduled payment date. I understand that 

this coverage is not renewable or extendable. I understand that the information contained herein is a summary of the coverage 

offered in the Certificate of Insurance and that I may obtain a complete copy of the Certificate of Insurance upon request to HCC 

Life. I understand that HCC Life, as underwriter of the plan, is solely liable for the coverage and benefits provided under the 

insurance. I understand and agree that the insurance agent/broker, if any, assisting with this application is a representative of 

the Applicant. If signed by a representative of the Applicant, the undersigned represents his/her capacity to so act. If signed as 

guardian or proxy of the Applicant, the undersigned represents his/her capacity to so act. By acceptance of coverage and/or 

submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. If I am not 

already a member of the Consumer Benefits of America Association, I hereby request to be enrolled as a member. I will receive 

a membership packet after my membership fees of $5 per month are received. Fraud Warning: Any person who knowingly and 

with intent to injure, defraud, or deceive any insurance company or other person submits an insurance application or statement 

of claim containing any materially false, incomplete or misleading information may be committing a crime and may be subject to 

civil or criminal penalties. 

Applicant Signature Date Spouse Signature Date 

Signed by HCC Life Appointed Agent: Plan Administrator Use Only: 

PBC 6CA.110.07.09 Code: 

Rate Calculation 

Use the rate table corresponding to your choice 

of plan option and coinsurance level to complete 

applicant rates below, then follow the calculation 

instructions. 

Monthly 

Payments 

Single Upfront Payment 

A Applicant’s Rate A A

B Spouse’s Rate B B

C Per child _________ x # ______ = C C 

D A + B + C = D D 

E Zip Code Factor E E 

F

D x E = Monthly / Daily 

Premium Total(round to the 

nearest penny) 

F F 

G Monthly / Daily Association 

Fee G G 

H F + G = Total Monthly / Daily 

Rate H H 

I Number of to be 

Covered n/a I 

J H x I = n/a J 

K Administrative Fee K K 

L Total Due Monthly: H + K= 

Daily: J + K = L L 

HCCL STMM ENR CA (01/09) 

Days

MOHOMMED AZAD 10.00 12-08-2015 0

12/08/2015 2.395 Zachary Zimmerman 0.00 46.60 MOHOMMED AZAD- Phone Sale ************6645 ✔

46.6 MOHOMMED AZAD 111.61 5.00 $126.61 0.00 0

116.61 06-2018

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 69 of 166
EXHIBIT 12 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 70 of 166
Medical Questions 

Please answer the questions below as they apply to the Applicant (Primary person listed 

above) applying for coverage. For each family member applying for coverage, complete and 

answer the questions on the Dependent Medical Questionnaire.

1. Will you have other health insurance in force on the policy effective date or be eligible for Medicaid? Yes No 

2. Have you: 

a. Been denied insurance due to any health reasons for a condition that is still present? 

b. Now pregnant, in process of adoption or undergoing infertility treatment? 

c. Over 300 pounds if male or over 250 pounds if female? 

 Yes No 

3. Within the last 5 years have you been diagnosed, treated, or taken medication for any of the following: 

cancer or tumor, stroke, heart disease including heart attack, chest pain or had heart surgery, COPD 

(chronic obstructive pulmonary disease) or emphysema, Crohn's disease, liver disorder, degenerative 

disc disease or herniation/bulge, rheumatoid arthritis, kidney disorder, diabetes, degenerative joint 

disease of the knee, alcohol abuse or chemical dependency, or any neurological disorder? 

 Yes No 

4. Within the last 5 years have you been diagnosed or treated by a physician or medical practitioner for 

Acquired Immune Deficiency Syndrome (AIDS)? 

 Yes No 

5. If you are not a US Citizen, do you expect to legally reside in the US for the duration of the policy? Yes No 

 US citizen 

If you have answered “Yes” to questions 1 through 4 or “No” to question 5 above, coverage cannot be issued. 

Thank you for your interest. 

California law prohibits an HIV test from being required or used by health insurance companies as a condition of 

obtaining health insurance coverage. 

HCC Life STM 

Enrollment Form 

For use in CA

Personal Details Please provide the following details for all individuals to be covered. 

Name (First and Last) Date of Birth Gender Contact Information 

Primary Male 

 Female 

Address 

Spouse Male 

 Female 

City State Zip 

Child 1 Male 

 Female 

Phone Number 

Child 2 Male 

 Female 

E-mail Address 

• Please complete this application entirely. Failure to provide 

complete information may delay processing. 

• You may elect the $5,000 and $7,500 deductible options by 

applying online or contacting us. 

Plan Options 

Please check the boxes corresponding to 

your elections for deductible and 

coinsurance.

Payment 

Option Monthly – 6 month plan 

Deductible $250 $500 $1,000 $2,500 $5,000 $7,500 Single Up Front (please specify term date)

Coinsurance 80% of $5,000 50% of $5,000 Specify Term Date ________________ 

Requested Effective Date _____/ ______ / _________ Number of days (max 180) _________

Please submit completed applications with 

payment to: 

HCC Life Insurance Company 

251 N. Illinois Street, Suite 600 

Indianapolis, IN 46204 

For product information or assistance with 

this enrollment form, please contact: 

 

HCCL STMM ENR CA (01/09) 

(Herein referred to as HCC Life)

2015 01-14- ✔

12 ✔

✔

✔

✔

✔

✔

✔

09 MOHOMMED AZAD ✔

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 71 of 166
Payment Information 

Please provide complete payment information. 

Applications without payment cannot be processed. 

Check/Money Order (Single Up-Front Payment 

Only) MasterCard VISA 

 Discover American Express

Credit Card Number Exp Date 

Name on Card 

Phone # 

Billing Address (including city, state and zip) 

Check or Money Orders should be made payable, in 

US dollars, to HCC Life Insurance Company. If 

paying by credit card, I authorize HCC Life to debit 

my Discover, VISA, MasterCard or American 

Express account for the amount specified in the 

Rate Calculation section. If I have selected a 

monthly plan, I hereby request and authorize HCC 

Life to debit my Credit Card account for the proper 

installment amounts on the due dates of the 

installments. This authorization will remain in effect 

for the duration of the Coverage Period elected or 

until revoked by me in writing. Coverage purchased 

by credit card is subject to validation and 

acceptance by the credit card company. 

Cardholder Signature Date 

Authorization 

I hereby request coverage under the insurance issued to the Consumer Benefits of America Association and underwritten by 

HCC Life Insurance Company. I understand this insurance contains a Pre-existing Condition exclusion, a Pre-certification 

Penalty and other restrictions and exclusions. I agree that coverage will not become effective for me or any dependent whose 

medical status, prior to the effective date, has changed and therefore results in a “yes” answer to any of the medical questions 

on this application. If my medical status changes in this way, coverage will be declined for all individuals included on this 

application. I understand that if I have elected the Monthly Payment option, my credit card will be charged each month on the 

due date of the premium for 6 months, depending on the plan I have selected. I understand that I may terminate the scheduled 

payments by notifying HCC Life in writing at least one business day prior to the next scheduled payment date. I understand that 

this coverage is not renewable or extendable. I understand that the information contained herein is a summary of the coverage 

offered in the Certificate of Insurance and that I may obtain a complete copy of the Certificate of Insurance upon request to HCC 

Life. I understand that HCC Life, as underwriter of the plan, is solely liable for the coverage and benefits provided under the 

insurance. I understand and agree that the insurance agent/broker, if any, assisting with this application is a representative of 

the Applicant. If signed by a representative of the Applicant, the undersigned represents his/her capacity to so act. If signed as 

guardian or proxy of the Applicant, the undersigned represents his/her capacity to so act. By acceptance of coverage and/or 

submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. If I am not 

already a member of the Consumer Benefits of America Association, I hereby request to be enrolled as a member. I will receive 

a membership packet after my membership fees of $5 per month are received. Fraud Warning: Any person who knowingly and 

with intent to injure, defraud, or deceive any insurance company or other person submits an insurance application or statement 

of claim containing any materially false, incomplete or misleading information may be committing a crime and may be subject to 

civil or criminal penalties. 

Applicant Signature Date Spouse Signature Date 

Signed by HCC Life Appointed Agent: Plan Administrator Use Only: 

PBC 6CA.110.07.09 Code: 

Rate Calculation 

Use the rate table corresponding to your choice 

of plan option and coinsurance level to complete 

applicant rates below, then follow the calculation 

instructions. 

Monthly 

Payments 

Single Upfront Payment 

A Applicant’s Rate A A

B Spouse’s Rate B B

C Per child _________ x # ______ = C C 

D A + B + C = D D 

E Zip Code Factor E E 

F

D x E = Monthly / Daily 

Premium Total(round to the 

nearest penny) 

F F 

G Monthly / Daily Association 

Fee G G 

H F + G = Total Monthly / Daily 

Rate H H 

I Number of to be 

Covered n/a I 

J H x I = n/a J 

K Administrative Fee K K 

L Total Due Monthly: H + K= 

Daily: J + K = L L 

HCCL STMM ENR CA (01/09) 

Days

MOHOMMED AZAD 10.00 12-08-2015 0

12/08/2015 2.395 Zachary Zimmerman 0.00 46.60 MOHOMMED AZAD- Phone Sale ************6645 ✔

46.6 MOHOMMED AZAD 111.61 5.00 $126.61 0.00 0

116.61 06-2018

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 72 of 166
EXHIBIT 13 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 73 of 166
HCCL STMM 102 CA 1 

HCC LIFE INSURANCE COMPANY 

225 TownPark Drive, Suite 350 

Kennesaw, Georgia 30144 

866-400-7102 

CERTIFICATE OF INSURANCE 

PROVIDING SHORT TERM MAJOR MEDICAL INSURANCE 

Group Policy No. STM600-1 (“the policy”), has been issued to Consumer Benefits of America 

which we will refer to as “the Policyholder”. We will refer to HCC Life Insurance Company as 

“the Company”, “we”, “us”, “our”. 

The policy was delivered in Missouri and will be governed by the laws thereof. 

This Certificate of Insurance is evidence of the Insured’s insurance under the policy and of its 

benefits. Everything contained in this Certificate of Insurance is subject to the provisions, 

definitions, and exceptions in the policy. The policy is on file with the Policyholder and may be 

examined at any reasonable time. Only one of our executive officers can authorize a change of 

the policy. 

This Certificate replaces all Certificates and Certificate Riders, if any, previously issued to the 

Insured under the policy. 

Signed for HCC Life Insurance Company: 

President: 

Corporate Secretary: 

 

THIS CERTIFICATE IS EVIDENCE OF A CONTRACT 

BETWEEN THE POLICYHOLDER AND THE COMPANY 

READ IT CAREFULLY

For service or complaints about this policy, please address any inquiries to 

the address shown above or call 866-400-7102. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 74 of 166
HCCL STMM 102 CA 2 

TABLE OF CONTENTS 

PART I GENERAL DEFINITIONS ................................................................ Page 3 

PART II ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE ........................ Page 7 

PART III TERMINATION OF INSURANCE ..................................................... Page 8 

PART IV PREMIUMS ...........................................................................................Page 10 

PART V DESCRIPTION OF MEDICAL EXPENSES ...................................... Page 11 

PART VI EXCLUSIONS........................................................................................Page 18 

PART VII COORDINATION OF BENEFITS ..........................................................Page 22 

PART VIII CLAIM PROVISIONS .................................................................................. Page 25 

PART IX GENERAL PROVISIONS ......................................................................Page 27 

PART X SCHEDULE OF BENEFITS ................................................................ Page 28 

OPTIONAL BENEFIT RIDERS, IF ANY 

AMENDMENT RIDERS, IF ANY 

NOTE: NO CONTINUOUS COVERAGE. This Certificate of insurance provides coverage 

for a short term duration only. It is not renewable. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 75 of 166
HCCL STMM 102 CA 3 

PART I – GENERAL DEFINITIONS 

“Accident” means a sudden, unforeseeable event that causes injury to one or more Covered 

Persons. 

“Complications of Pregnancy” means: 

1. Conditions requiring Inpatient treatment (when pregnancy is not terminated); 

2. Whose diagnoses are distinct from pregnancy but are adversely affected or caused by 

pregnancy, such as hyperemesis gravidarum, preeclampsia, acute nephritis, nephrosis, 

cardiac decompensation, missed abortion and similar medical and surgical conditions of 

comparable severity, but shall not include false labor, occasional spotting, Doctor 

prescribed rest during the period of pregnancy, morning Sickness, and other similar 

conditions associated with the management of a difficult pregnancy not constituting a 

nosologically distinct complication of pregnancy; and 

3. Non-scheduled or emergency cesarean section, ectopic pregnancy that is terminated, 

and spontaneous termination of pregnancy that occurs during a period of gestation in 

which a viable birth is not possible. 

“Congenital Condition” means a disease or other anomaly existing at or before birth, whether 

acquired during development or by heredity. 

“Coverage Period” means the length of time which the Insured selected in the Insured’s 

application and approved by us, not to exceed a month period commencing on the 

Effective Date. The Insured’s Coverage Period is shown in the Schedule of Benefits. 

“Covered Person” means an Insured and his eligible dependents for whom coverage is in effect 

under the policy, as described in Part II – Eligibility and Effective Date of Insurance Provisions 

and the Schedule of Benefits. 

“Custodial or Convalescence Care” means any care that is provided to a Covered Person who 

is disabled and needs help to support the essential activities of daily living when the Covered 

Person is not under active and specific medical, surgical, or psychiatric treatment that will 

reduce the disability to the extent necessary for the person to perform the essentials of daily 

living on his own. 

“Deductible” means the amount of covered expenses that must be paid by a Covered Person 

before benefits are payable under the policy. This amount applies separately to each Covered 

Person and must be satisfied each Coverage Period. 

“Doctor” means any duly licensed practitioner who is recognized by the law of the state in which 

treatment is received as qualified to perform the service for which claim is made. 

“Eligible Dependent” means: 

1. The Insured’s lawful spouse; and 

2. The Insured’s unmarried children who are less than age 19. An unmarried child who is 

less than age 25 may also be included if the child is enrolled full-time in an accredited 

school or college. 

Dependent children may include stepchildren, foster children, legally adopted children, children 

of adopting parents pending finalization of adoption procedures, and children for whom 

coverage has been court-ordered. 

6 [Six]

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 76 of 166
HCCL STMM 102 CA 4 

Dependent children (other than those for whom coverage has been court-ordered) must be 

primarily dependent on the Insured for principal support and maintenance. 

Coverage for an unmarried dependent child who is: 

A. incapable of self sustaining employment by reason of a physically or mentally disabling 

injury, illness or condition; who became so incapacitated prior to the attainment of the 

limiting age set forth above, and 

B. chiefly dependent upon the Insured for support and maintenance, shall not terminate. 

Coverage shall continue as long as the certificate remains in force and the dependent is 

disabled. Proof of such incapacity and dependency must be furnished to Us within sixty 

(60) of receipt of notice by Us that such coverage will terminate. We will provide such 

notice at least 90 days prior to the date the Dependent child attains the limiting age. 

Continued proof may be requested, but not more frequently than once a year. 

“Durable Medical Equipment” means medical equipment that can withstand repeated use, is 

prescribed by a Physician, and is appropriate for use in the home. Covered DME is limited to a 

standard basic Hospital bed and/or a standard basic wheel chair. 

“Effective Date” means the date the Insured’s (and Eligible Dependents’ if applicable) coverage 

under the policy is effective. 

“Experimental Treatment” means in Our discretion a treatment, drug, device, procedure, supply 

or service and related services (or any portion thereof, including the form, administration or 

dosage) for a particular diagnosis or condition when any one of the following exists: 

1. The treatment, drug, device, procedure, supply or service is in any clinical trial or a 

Phase I, II or III trial. 

2. The treatment, drug, device, procedure, supply or service is not yet fully approved or 

recognized (for other than experimental, investigational, research or clinical trial 

purposes) by the National Cancer Institute (NCI), Food & Drug Administration (FDA), or 

other pertinent governmental agency or professional organization. 

3. The results are not proven through controlled clinical trials with results published in peerreviewed English language medical journals, to be of greater safety and efficacy than 

conventional treatment, in both the short and long term. 

4. The treatment, drug, device, procedure, supply or service is not generally accepted 

medical practice in the state where the Covered Person resides or as generally accepted 

throughout the United States as determined in Our discretion, by reference to any one or 

more of the following: peer-reviewed English-language medical literature, consultation 

with physicians, authoritative medical compendia, the American Medical Association, or 

other pertinent professional organization or governmental agency. 

5. The treatment, drug, device, procedure, supply or service is described as investigational, 

experimental, a study, or for research or the like in any consent, release or authorization 

which the Covered Person, or someone acting on his or her behalf, may be required to 

sign. 

The fact that a procedure, service, supply, treatment, drug, or device may be the only hope for 

survival will not change the fact that it is otherwise experimental in nature. 

“Extended Care Facility” means an institution, other than a Hospital, operated and licensed 

pursuant to law, that provides: 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 77 of 166
HCCL STMM 102 CA 5 

1. Permanent and full-time facilities for the continuous skilled nursing care of three (3) or 

more sick or injured persons on an Inpatient basis during the convalescent stage of their 

illnesses or injuries; 

2. Full-time supervision of a Doctor; 

3. Twenty-four (24) hour a day nursing service of one or more Nurses; and 

4. Is not, other than incidentally, a rest home or a home for custodial care or for the aged. 

Extended Care Facility does not include an institution that primarily engages in the care 

and treatment of drug addiction or alcoholism. 

“Home Health Care Agency” means an entity licensed by state or local law operated primarily to 

provide skilled nursing care and therapeutic services in an individual’s home and: 

1. Which maintains clinical records on each patient; 

2. Whose services are under the supervision of a Doctor or a licensed graduate registered 

nurse (RN); and 

3. Which maintains operational policies established by a professional group including at 

least one Doctor and one licensed graduate registered nurse (RN). 

“Home Health Care Plan” means a program for continued care and treatment of an individual 

established and approved in writing by the individual’s attending Doctor. As part of the plan, an 

attending Doctor must certify that proper treatment of the Injury or Sickness would require 

continued confinement in a Hospital in the absence of the services and supplies. 

“Hospital” means an institution operated by law for the care and treatment of injured or sick 

persons; has organized facilities for diagnosis and surgery or has a contract with another 

hospital for these services; and has 24-hour nursing service. Hospital excludes any institution 

that is primarily a rest home, nursing home, convalescent home, a home for the aged, an 

alcoholism or drug addiction treatment facility. 

“Immediate Family” means the parents, spouse, children, or siblings of a Covered Person, or 

any person residing with a Covered Person. 

“Injury” means accidental bodily Injury of a Covered Person: 

1. Caused by an Accident; and 

2. That results in covered loss directly and independently of all other causes. 

All Injuries sustained in one Accident, including all related conditions and recurring symptoms of 

the Injuries, will be considered one injury. 

“Inpatient” means a person who incurs medical expenses for at least one day’s room and board 

from a Hospital. 

“Insured” means a person who meets the eligibility requirements for an Insured as stated in the 

Master Application and the policy, and whose coverage under the policy has become effective 

and has not terminated. 

“Medically Necessary” means the care, service or supply is: 

1. Prescribed by a Doctor for the diagnosis or treatment of an Injury or Sickness; and 

2. Appropriate, according to conventional medical practice for the Injury or Sickness in the 

locality in which the care, service or supply, is given. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 78 of 166
HCCL STMM 102 CA 6 

“Mental and Nervous Disorder” means a “biologically-based” mental disorder, including 

Schizophrenia, Schizoaffective disorder, Major depressive disorder, Bipolar disorder, Paranoia 

and other psychotic disorders, Obsessive-compulsive disorder, Panic disorder, Delirium and 

dementia, Affective disorders, and any other "biologically-based" mental disorders appearing in 

the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric 

Association (the "DSM"). 

“Outpatient” means a person who incurs medical expenses at Doctor’s offices and freestanding 

clinics, and at Hospitals when not admitted as an Inpatient. 

“Regular and Customary Activities” means an Insured Person can carry on a substantial part of 

the standard and commonly practiced activities of a person in good health of the same sex and 

age. Activities performed while confined in a Hospital or other medical institution may not be 

used to meet this requirement. 

“Routine Physical Exam” means examination of the physical body by a Doctor for preventive or 

informative purposes only, and not for the diagnosis or treatment of any condition. 

“Sickness” means Sickness or disease of a Covered Person that: 

1. Is treated by a Doctor while the person is covered under the policy; and 

2. Results directly and independently of all other causes in loss covered by the policy. 

“Substance Abuse” means the overindulgence in and dependence on a psychoactive leading to 

effects that are detrimental to the individual's physical health or mental health, or the welfare of 

others. 

“Surgery or Surgical Procedure” means an invasive diagnostic procedure; or the treatment of 

Injury or Sickness by manual or instrumental operations performed by a Doctor while the patient 

is under general or local anesthesia. 

“Total Disability” (or “Totally Disabled”) means the Insured is disabled and prevented from 

performing the material and substantial duties of his or her occupation. For Dependents, 

“Totally Disabled” means the inability to perform a majority of the normal activities of a person of 

like age in good health. 

“Urgent Care Center” means a medical facility separate from a hospital emergency department 

where ambulatory patients can be treated on a walk-in basis without an appointment and 

receive immediate, non-routine urgent care for an Injury or Sickness presented on an episodic 

basis. 

“Usual and Customary” charges means the following: 

1. A usual fee is defined as the charge made for a given service by a Doctor to the majority 

of his or her patients; and 

2. A customary fee is one that is charged by the majority of Doctors within a community for 

the same services. All benefits are limited to Usual and Customary charges. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 79 of 166
HCCL STMM 102 CA 7 

PART II – ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE 

Coverage will be effective for an Insured and his Eligible Dependent(s) as of the approved 

Effective Date, provided: 

1. The Insured meets the eligibility requirements set forth in the Master Application and the 

Policy; 

2. The Insured's Application is approved by Us; 

3. The first premium payment is received on or before the date the Insured's Application is 

approved by Us; 

4. The Insured is not confined at home or in a Hospital or medical institution as of the 

Effective date; and 

5. The Insured is engaging in his Regular and Customary Activities as of the Effective date. 

If the Insured is not engaged in his Regular and Customary Activities or is confined in a Hospital 

or medical institution on the Effective Date, coverage will begin the first day he can engage in 

his Regular and Customary Activities and is not confined in a Hospital or medical institution. 

The Company will require satisfactory evidence of insurability for each Insured and Eligible 

Dependent. 

Newborn Child Coverage: A child of the Insured born while the policy is in force is covered for 

Injury and Sickness (including necessary care and treatment of congenital defects, birth 

abnormality and premature birth), as well as routine newborn care for the first 31 days. The 

child is covered from the moment of birth until the 31st day of age. A notice of birth together with 

additional premium must be submitted to us within 31 days of the birth in order to continue 

coverage for Injury and Sickness beyond the initial 31-day period. 

Adopted Children Coverage: A minor child who comes under the charge, care and control of 

the Insured while the policy is in force is covered for Injury and Sickness provided the Insured 

files a petition to adopt. The coverage of such child will be the same as provided for other 

members of the Insured’s family. Such child shall be covered from the date of placement in the 

Insured’s home if the Insured applies for coverage and pays any required premium within 31 

days after the date of placement. However, coverage shall begin at the moment of birth if the 

petition for adoption, application for coverage and payment of premium occurs within 31 days 

after the child’s birth. Such child’s coverage will not be subject to any pre-existing conditions 

limitation provided by the policy. Coverage for such minor child will continue unless the petition 

for adoption is dismissed or denied. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 80 of 166
HCCL STMM 102 CA 8 

PART III - TERMINATION OF INSURANCE 

Coverage of a Covered Person under the Policy shall automatically terminate on the earliest of 

the following dates: 

1. The date the Coverage Period expires; 

2. The first day of the month coinciding with or following the date other hospital, major 

medical, group health or other medical insurance coverage becomes effective for a 

Covered Person; 

3. The end of the last period for which the last required premium payment was made for 

the Insured’s or Covered Person’s insurance; 

4. The date a Covered Person receives the Coverage Period Maximum Benefit Amount; 

5. The date the Covered Person enters the armed forces of any country, state or 

international organization, other than for reserve duty of 30 days or less; 

6. The premium due date that coincides with or next follows the date on which the Insured 

is no longer eligible; 

7. For a Dependent spouse, the first day of the month following the date of divorce or legal 

separation from the Insured; or 

8. The date We specify that the Covered Person’s insurance is terminated because of: 

A. Failure to provide any signed release, consent, assignment or other documents 

requested by Us; 

B. Failure to fully cooperate with Us in the administration of the Policy; 

C. Material misrepresentation, fraud, or omission of information on any application 

form, or in requesting the receipt of benefits under the Policy; or 

D. Misuse of the Covered Person's identification card. 

At the death of an Insured, all rights and privileges as a Covered Person under the Policy will 

transfer to the surviving Dependent spouse. The Dependent spouse will then be considered an 

Insured instead of a Dependent. In the event the Dependent spouse remarries, coverage under 

the Policy for the Dependent Spouse and Dependent child(ren), if any, will end on the first day 

of the month following the date of that marriage. If no surviving Dependent spouse, or at the 

death of a surviving Dependent spouse, all rights and privileges as a Covered Person under the 

Policy will transfer to each Dependent child, if any, and he will be considered the Insured 

instead of a Dependent. 

If the Insured selected the Pay In Advance option in the Insured's Application and We received 

all required premium for the Coverage Period, premium will be reimbursed to the Insured for the 

period of time, if any, between the date coverage terminates in accordance with the above 

provisions and the end of that Coverage Period. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 81 of 166
HCCL STMM 102 CA 9 

Extension of Benefits 

If a covered Bodily Injury or Sickness commences while the Policy is in force as to a Covered 

Person, benefits otherwise payable under the Policy for the Injury or Sickness causing the Total 

Disability will also be paid for any Eligible Expenses incurred after the termination of insurance 

for a Covered Person if, from the date of such termination to the date such expenses are 

incurred, the Covered Person is Totally Disabled by reason of such Injury or Sickness. Such 

benefits shall be payable only during the continuance of such disability until the earlier of: 

1. The date the Total Disability ends; 

2. The date when treatment for the Total Disability is no longer required; 

 3. The date following a time period equal to the Covered Person's Coverage Period, with a 

minimum of thirty (30) days not to exceed a maximum of ninety (90) days; 

 4. The date the Covered Person becomes eligible for any other group insurance plan 

providing coverage for the same conditions causing the Total Disability; or 

 5. The date the Coverage Period Maximum Benefit amount has been reached

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 82 of 166
HCCL STMM 102 CA 10 

PART IV - PREMIUMS 

1. Unless the Pay In Advance option has been chosen, premium due dates for an Insured 

will be on the Effective Date and then the same date of each following calendar month. If a 

month has fewer days than the scheduled premium due date, premium will be due on the last 

day of the month. All insurance shall be charged from and to the premium due date. 

2. If any change or clerical error affects premiums, an equitable adjustment in premiums 

shall be made on the premium due date next following the date of the change or the discovery of 

the error. Any premium adjustment that involves collecting earned premiums, or returning 

unearned premium shall be limited to the six (6) months immediately preceding the date of 

determination that the adjustment in premium should be made. 

3. Premiums shall be payable in advance to Us at Our Home Office. 

4. If the Insured has not given written notice to Us that insurance is to be terminated prior to 

the premium due date, a grace period of thirty-one (31) days beginning from the premium due 

date will be allowed for any premium after the first premium. If the Insured fails to pay premium 

before the grace period expires all coverage shall lapse as of the premium due date. 

5. The Policy does not share in the surplus earnings of the Company and no refund or 

assessment shall be made to the Policyholder, Insured, or Dependent of any excess or deficit 

earnings of the Company. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 83 of 166
HCCL STMM 102 CA 11 

PART V – DESCRIPTION OF MEDICAL EXPENSES 

Subject to the Deductible, Coinsurance and other limits set forth in PART X – SCHEDULE OF 

BENEFITS, the Company will pay the following expenses incurred while this insurance is in 

effect: 

1. Charges made by a Hospital for: 

A. Daily room and board and nursing services not to exceed the average semiprivate room rate; 

B. Daily room and board and nursing services in Intensive Care Unit; 

C. Use of operating, treatment or recovery room; 

D. Services and supplies which are routinely provided by the Hospital to persons for 

use while Inpatients; 

E. Emergency treatment of an Injury, even if Hospital confinement is not required; 

and 

F. Emergency treatment of a Sickness; however, an additional $250 Deductible will 

apply to emergency room charges unless the Covered Person is directly 

admitted to the Hospital as an Inpatient for further treatment of that Sickness. 

2. For Surgery at an Outpatient surgical facility, including services and supplies. 

3. For charges made by a Doctor for professional services. 

4. For charges made by a Doctor for Surgery. Charges for an assistant surgeon are 

covered up to 20% of the Usual and Customary charge of the primary surgeon. 

(Standby availability will not be deemed to be a covered charge.). 

5. For dressings, sutures, casts or other supplies which are Medically Necessary and 

administered by or under the supervision of a Doctor, but excluding nebulizers, oxygen 

tanks, diabetic supplies, other supplies for use or application at home, and all devices or 

supplies for repeat use at home, except Durable Medical Equipment as herein defined. 

6. For diagnostic testing using radiology, ultrasonographic or laboratory 

services 

(psychometric, intelligence, behavioral and educational testing are not included). 

7. For artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial 

limbs, 

but not the replacement or repair thereof. 

8. For reconstructive surgery performed to correct or repair abnormal structures of the body 

caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or 

disease: 

A. to im pro ve f unct ion; or 

B. to create a normal appearance, to the extent possible. 

9. Reconstructive breast surgery and prosthetic devices incident to a Mastectomy. 

Coverage will also be extended to include surgery on a non-diseased breast to establish 

symmetry with the diseased breast. As used in this benefit: 

A. “Mastectomy” means the surgical removal of all or part of a breast as a result of 

breast cancer. 

B. “Reconstructive breast surgery” means surgery performed as a result of a 

mastectomy to reestablish symmetry between the two breasts and includes 

augmentation mammoplasty, reductive mammoplasty, and mastopexy. 

Coverage for prosthetic devices and reconstructive surgery means any initial or 

subsequent surgeries, prosthetic devices and any Medically Necessary follow up care. 

10. For radiation therapy or treatment and chemotherapy. 

11. For hemodialysis and the charges by the Hospital for processing and administration of 

blood or blood components but not the cost of the actual blood or blood components. 

12. For oxygen and other gasses and their administration by or under the 

supervision of a doctor. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 84 of 166
HCCL STMM 102 CA 12 

13. For anesthetics and their administration by a Doctor, subject to a maximum of 20% of 

the benefit payable for the primary surgeon. 

14. Extended Care Facility charges for room and board accommodations; if: 

A. The Insured is an Inpatient in that facility on the certification of the attending 

Doctor that the confinement is Medically Necessary;

B. The confinement commences immediately following a period of at least three (3) 

continuous days of Hospital confinement; and 

C. That confinement is for the same covered Injury or Sickness that was treated 

during the Covered Person's confinement in the Hospital. 

15. Treatment of a Covered Person by a Home Health Care Agency under a Home Health 

Care Plan. Up to four (4) consecutive hours in a twenty-four (24) hour period of Home 

Health Care services shall be considered as one Home Health Care visit. Eligible 

Expenses for Home Health Care are the Maximum Allowable Charges made for the 

following: 

A. Part-time skilled nursing care; 

B. Ph ys ic a l t h e r a p y; 

C. S p e e c h t h e r a p y ; 

D. Medical supplies, drugs and medicines prescribed by a Doctor; 

E. Laboratory services by or on behalf of the Hospital but only to the extent benefits 

for those services would have been paid under the Policy had the Insured Person 

remained Hospitalized; 

F. Occupational therapy; and 

G. R e s p i r a t o r y t h e r a p y . However, benefits will not be paid for charges 

made by a Home Health Care Agency for: 

A. Any charges excluded under the Exclusions of the certificate; 

B. Full-time nursing care at home; 

C. Meals delivered to the home; 

D. Homemaker services; 

E. Any services of an individual who ordinarily resides in the Insured’s home or is a 

member of the Insured's immediate family; or 

F. Any transportation services. 

Benefits for Home Health Care are in lieu of any similar benefits provided under any 

other provision of the certificate. 

16. Local Ambulance transport necessarily incurred in connection with Injury, and Local 

Ambulance transport necessarily incurred in connection with Sickness resulting in 

Inpatient hospitalization. 

17. Dental treatment and dental surgery necessary to restore or replace natural teeth lost or 

damaged as a result of an Injury covered under this certificate. 

18. Medically Necessary rental of Durable Medical Equipment (limited to a standard basic 

hospital bed and/or a standard basic wheelchair) up to the purchase prices, not including 

expenses for customization and only for the portion of the cost equivalent to the 

Coverage Period. 

19. Physical Therapy if prescribed by a Doctor who is not affiliated with the Physical Therapy 

practice, necessarily incurred to continue recovery from a covered Injury or Sickness. 

Pre-Certification Requirements 

1. All hospitalizations, other Inpatient care, and Surgeries or Surgical Procedures must be 

Pre-certified. 

2. To comply with the Pre-certification requirements, the Covered Person must: 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 85 of 166
HCCL STMM 102 CA 13

A. Contact the Company at 1-866-400-7102 as soon as possible before the 

expense is to be incurred; and 

B. Comply with the instructions of the Company and submit any information or 

documents they require; and 

C. Notify all Doctors, Hospitals and other providers that this insurance contains Precertification requirements and ask them to fully cooperate with the Company.

 3. If the Covered Person complies with the Pre-certification requirements, and the 

expenses are Pre-certified, the Company will pay Eligible Medical Expenses subject to 

all terms, conditions, provisions and exclusions described in this certificate. If the 

Covered Person does not comply with the Pre-certification requirements or if the 

expenses are not Pre-certified: 

A. Eligible Medical Expenses will be reduced by 50%; and 

B. The Deductible will be subtracted from the remaining amount; and 

C. The Coinsurance will be applied. 

 4. Emergency Pre-certification: In the event of an emergency Hospital admission, Precertification must be made within 48 hours after the admission, or as soon as is 

reasonably possible. 

 5. Pre-certification Does Not Guarantee Benefits – The fact that expenses are Pre-certified 

does not guarantee either payment of benefits or the amount of benefits. Eligibility for 

and payment of benefits are subject to all the terms, conditions, provisions and 

exclusions herein. 

 6. Concurrent Review – For Inpatient stays of any kind, the Company will Pre-certify a 

limited number of days of confinement. Additional days of Inpatient confinement may 

later be Pre-certified if a Covered Person receives prior approval. 

Pre-Certification Requirements for reconstructive surgery in connection with a mastectomy shall 

not be required in determining length of stay in a hospital following such surgery or procedure. 

Only a Doctor competent to evaluate the specific clinical issues involved in the care requested, 

can deny a request to authorize care for reconstructive surgery. 

State Mandated Benefits. 

The following benefits are mandated by applicable state law. All benefits will be subject to any 

inside benefit limitations set forth below, as well as the Coverage Period Maximum Benefit 

amounts shown on the Schedule of Benefits. 

 1. Dental Anesthesia – Coverage shall be provided for general anesthesia for dental care 

for a Dependent child if an underlying medical condition requires such anesthesia to be 

provided in a hospital or surgery center setting. Coverage shall only include payment 

for: 

A . a n e s t h e s i a ; a n d 

B . hospital or surgery center setting charges. 

The Dependent child must meet the following conditions: 

A. be under the age of seven (7); or 

B. be developmentally disabled, regardless of age; and 

C. it is determined that such child's health is compromised and general anesthesia 

is Medically Necessary. 

 2. Child Preventive Care - Coverage shall be provided for comprehensive child preventive 

care consistent with the following for children 16 years of age or younger: 

A. The recommendations for Preventive Pediatric Health Care, as adopted by the 

American Academy of Pediatrics of September 1987; 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 86 of 166
HCCL STMM 102 CA 14

B. The most current version of the Recommended Childhood Immunization 

Schedule/United States, jointly adopted by the: 

(a) American Academy of Pediatrics; 

(b) Advisory Committee on Immunization Practices; and 

(c) American Academy of Family Physicians; 

unless the State Department of Health Services determines, within 45 days of the 

published date of the schedule, that the schedule is not consistent with the 

purposes of this benefit provision. and 

C. Include benefits for: 

(a) periodic health evaluations; 

(b) immu nizat ions; an d 

(c) laboratory services in connection with periodic health evaluations. 

 3. Mammography Screening - Coverage shall be provided for the screening and

diagnosis of breast cancer based on the following: 

A. A baseline mammogram for a woman who is thirty-five (35) to forty (40) years of 

age; 

B. A mammogram for a woman who is forty (40) to forty-nine (49) years of age, 

every two years, or more frequently, based on the recommendation of the 

woman’s Doctor; 

C. A mammogram each year for a woman who is at least fifty years (50) of age; 

 4. Laryngectomy - Coverage shall be provided for prosthetic devices to restore speech 

after a laryngectomy. 

As used here: 

Laryngectomy means the Medically Necessary removal of the larynx. 

Prosthetic devices means initial and replacement prosthetic devices, including 

installation accessories prescribed by a Doctor. It does not include an electronic voice 

producing machine. 

 5. Prostate Screenings - Coverage shall be provided for the screening and diagnosis of 

prostate cancer. Coverage shall include, but not be limited to: 

A. prostate specific antigen testing; and 

B. digital rectal examinations. 

Coverage does not include: 

A. radical prostatectomy; 

B. external beam radiation therapy; 

C. radiation seed implants; or 

D. combined hormonal therapy. 

 6. Cervical Cancer Screenings - Coverage shall be provided for an annual cervical 

cancer screening test including a Pap test or any cervical cancer screening test 

approved by the FDA and recommended by a Doctor. 

 7. Cancer Screening Tests - Coverage shall be provided for generally medically accepted 

cancer screening tests. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 87 of 166
HCCL STMM 102 CA 15

8. Phenylketonuria (PKU) Treatment - Coverage shall be provided for the testing and 

treatment of phenylketonuria (PKU). Such coverage will include formulas and special 

food products that are: 

A. part of a diet prescribed by a Doctor; 

B. managed by a health care professional in consultation with a Doctor who 

specializes in the treatment of metabolic disease. 

Such diet must be Medically Necessary to avoid the development of a serious physical 

or mental disability; or to promote normal development or function as a consequence of 

PKU. Coverage is only required to the extent it exceeds the cost of a normal diet. 

As used here: 

"Formula" means an enteral product for use at home that is prescribed or ordered by a 

Doctor or other authorized health care provider as Medically Necessary for the treatment 

of PKU. 

"Special food products" means a food product that is both: 

A. prescribed by a Doctor for the treatment of PKU and consistent with the 

recommendations and best practices of qualified health professionals with 

expertise germane to, and experience in the treatment and care of, PKU. It does 

not include a food that is naturally low in protein, but may include a food product 

that is specially formulated to have less than one gram of protein per serving; 

and 

B. used in place of normal food products, such as grocery store foods , used by the 

general population. 

9. Osteoporosis - Coverage shall be provided for the diagnosis, treatment and appropriate 

management of osteoporosis. Coverage will include, but not be limited to, FDA 

approved technologies such as bone mass measurement, as deemed medically 

appropriate. 

10. Severe Mental Illness/Serious Emotional Disturbances of a Child - Coverage for 

Medically Necessary treatment shall be provided for: 

A. diagnosis and treatment of severe mental illness for a Covered Person of any 

age; and 

B. emotional disturbances of a child who: 

(a) has one or more mental disorders as identified in the most recent edition 

of the Diagnostic and Statistical Manual of Mental Disorders, other than a 

primary substance use disorder or developmental disorder, that result in 

behavior inappropriate to such child's age according to expected 

development norms; and 

(b) meets one or more of the following: 

(i) displays psychotic features, risk of suicide, or risk of violence due 

to a mental disorder; or 

(ii) meets special education eligibility requirements pursuant to 

California state law; or 

(iii) has substantial impairment, as a result of the mental disorder, in 

at least two of the following areas: self-care, school functioning, 

family relationships, or ability to function in the community and 

either of the following occur: the child is at risk of removal from 

his/her home or has already been removed from the home; or the 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 88 of 166
HCCL STMM 102 CA 16

mental disorder and impairments have been present for more than 

six months or are likely to continue for more than one year without 

treatment. 

Benefits shall include charges incurred for: 

1. Outpatient services; 

2. Inpatient hospital services, including inpatient prescription drugs and 

3. Partial hospital services. 

As used here: 

"Severe mental illness" shall include: 

1. Schizophrenia or schizoaffective disorder; or 

2. Bipolar disorder (manic-depressive illness); or 

3. Major depressive disorder; or 

4. Pa n ic d is o r d e r ; o r 

5. Obsessive-compulsive disorder; or 

6. Pervasive developmental disorder or autism; or 

7. Anorexia nervosa or bulimia nervosa. 

 11. Diabetes - Coverage shall be provided for Medically Necessary supplies, equipment and 

management and treatment of insulin using diabetes, non-insulin using diabetes and 

gestational diabetes. Coverage shall include: 

A. Blood glucose monitors, including glucose monitors for the visually impaired; 

B. Blood glucose test strips, ketone urine testing strips; 

C. Insulin pumps and related necessary supplies; 

D. Lancets and lancet puncture devices; 

E. pen delivery systems for the administration of insulin; 

F. Podiatric devices to prevent or treat diabetes related complications; 

G. I n s u l in s yr in g e s ; 

H. Visual aids (but not eyewear) to assist the visually impaired with proper dosing of 

insulin. 

Coverage shall also include outpatient self-management training, education and medical 

nutrition therapy services necessary to enable the Covered Person to properly use the 

equipment and supplies listed above. Such services must be provided by an 

appropriately licensed or registered health care professional as prescribed by a health 

care professional legally authorized to prescribe the services. 

 12. AIDS Vaccine – Coverage shall be provided for a vaccine for Acquired Immune 

Deficiency Syndrome (AIDS) that is approved by the FDA and recommended by the U.S. 

Public Health Service. 

 13. Cancer Clinical Trials - Coverage shall be provided for routine patient costs for a 

Covered Person diagnosed with cancer and accepted into a phase I, phase II, phase III, 

or phase IV clinical trial for cancer. The Covered Person’s Doctor must recommend 

participation in the clinical trial and determine that it will have a meaningful potential 

benefit. Treatment must be provided in a clinical trial that: 

A. involves a drug that is exempt under federal regulations from a new drug 

application; or 

B. is approved by one of the following: 

(a) one of the National Institutes of Health (NIH);

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 89 of 166
HCCL STMM 102 CA 17

(b) the FDA, in the form of an investigational new drug application; 

(c) the U.S. Department of Defense; or 

(d) the U.S. Veterans’ Administration. 

“Routine patient costs” means costs associated with the provision of health care 

services, including drugs, items, devices, and services that would otherwise be covered 

under the plan or contract if those drugs, items, devices, and services were not provided 

in connection with an approved clinical trial program, including the following: 

A. Health care services typically provided absent a clinical trial. 

B. Health care services required solely for the provision of the investigational drug, 

item, device, or service. 

C. Health care services required for the clinically appropriate monitoring of the 

investigational item or service. 

D. Health care services provided for the prevention of complications arising from the 

provision of the investigational drug, item, device, or service. 

E. Health care services needed for the reasonable and necessary care arising from 

the provision of the investigational drug, item, device, or service, including the 

diagnosis or treatment of the complications. 

It does not include: 

A. drugs or devices not approved by the FDA and that are associated with the clinical 

trial; 

B. services other than health care services, such as travel, housing, companion 

expenses and other nonclinical expenses; 

C. any item or service that is provided solely to satisfy data collection and analysis 

needs and that is not used in the clinical management of the patient. 

D. health care services which, except for the fact that they are not being provided in a 

clinical trial, are otherwise specifically excluded under this certificate; or 

E. health care services customarily provided by the research sponsors free of charge 

for any enrollee in the trial. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 90 of 166
HCCL STMM 102 CA 18

PART VI – EXCLUSIONS 

Charges for the following treatments and/or services and/or supplies and/or conditions are 

excluded from coverage: 

 1. Pre-existing Conditions – Charges resulting directly or indirectly from a condition for 

which a Covered Person received medical treatment, diagnosis, care or advice within 

the six (6) month period immediately preceding such person’s Effective Date are 

excluded for the first six (6) months of coverage hereunder. A Covered Person who 

was covered under creditable coverage within 63 days of enrolling under this certificate 

shall be given credit for the period of time under such coverage toward the satisfaction 

of this exclusion. This exclusion does not apply to a newborn or newly adopted child 

who is added to coverage under this certificate in accordance with PART II – 

ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE. Creditable Coverage means 

any of the following: 

A. A g rou p h ea lth p lan; or 

B. Health insurance coverage (care under any hospital or medical service policy or 

certificate; hospital or medical service plan contract; or Health Maintenance 

Organization (HMO); or 

C. In d ividua l co verag e; or 

D. M e d i c a r e ; o r 

E. M e d i c a i d ; o r 

F. C H A M P U S ; o r 

G. A medical care program of the Indian Health Service or of a tribal organization; 

or 

H. A State health benefits risk pool; or 

I. A health plan offered under the Federal Employees Health Benefits Program 

(FEHBP); or 

J. A public health plan; or 

K. A health benefit plan under the Peace Corps Act.

Creditable coverage does not include accident only, credit, coverage for onsite medical 

clinics, disability income, Medicare supplement, long-term care insurance, dental, 

vision, coverage issued as a supplement to liability insurance, workers’ compensation 

insurance or similar law, automobile medical payment insurance, or insurance under 

which benefits are payable with or without regard to fault and that is statutorily required 

to be contained in any liability insurance policy or equivalent self-insurance. 

Any coverage under which an insured was covered prior to a break in coverage of 63 

consecutive days or more, not counting any waiting period or affiliation period required 

by any Creditable Coverage, will not be considered Creditable Coverage. 

 2. Outpatient Prescription Drugs, medications, vitamins, and mineral or food supplements 

including pre-natal vitamins, or any over-the-counter medicines, whether or not ordered 

by a Doctor. 

 3. Routine pre-natal care, Pregnancy, childbirth, and postnatal care. (This exclusion does 

not apply to “Complications of Pregnancy” as defined.) 

 4. Alcoholism. 

 5. Substance abuse. 

 6. Charges which are not incurred by a Covered Person during his/her Coverage Period. 

 7. Treatment, services or supplies, which are not administered by or under the supervision 

of a Doctor. 

 8. Treatment, services or supplies which are not Medically Necessary as defined. 

 9. Treatment, services or supplies provided at no cost to the Covered Person. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 91 of 166
HCCL STMM 102 CA 19

10. Charges which exceed Usual and Customary charge as defined. 

11. Telephone consultations or failure to keep a scheduled appointment. 

12. Consultations and/or treatment provided over the Internet. 

13. Surgeries, treatments, services or supplies which are deemed to be Experimental 

Treatment. 

14. All charges Incurred while confined primarily to receive Custodial or Convalescence 

Care. 

15. Weight modification or surgical treatment of obesity, including wiring of the teeth and all 

forms of intestinal bypass surgery. 

16. Modifications of the physical body in order to improve the psychological, mental or 

emotional well-being of the Covered Person, such as sex-change surgery. 

17. Surgeries, treatments, services or supplies for cosmetic or aesthetic reasons, except for 

reconstructive surgery which is expressly covered under this certificate. 

18. Any drug, treatment or procedure that either promotes or prevents conception including 

but not limited to: artificial insemination, treatment for infertility or impotency, 

sterilization or reversal of sterilization. 

19. Any drug, treatment or procedure that either promotes, enhances or corrects impotency 

or sexual dysfunction. 

20. Abortions, except in connection with covered Complications of Pregnancy or if the life of 

the expectant mother would be at risk. 

21. Dental treatment, except for dental treatment that is expressly covered under this 

certificate. 

22. Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual 

therapy, and any examination or fitting related to these devices, and all vision and 

hearing tests and examinations. 

23. Eye surgery, such as radial keratotomy, when the primary purpose is to correct 

nearsightedness, farsightedness or astigmatism. 

24. Treatment for cataracts. 

25. Treatment of the temporomandibular joint, except for medically necessary surgical 

procedures for covered conditions directly affecting the upper or lower jawbone or 

associated bone joints. 

26. Injuries resulting from participation in any form of skydiving, scuba diving, auto racing, 

bungee jumping, hang or ultra light gliding, parasailing, sail planing, flying in an aircraft 

(other than as a passenger on a commercial airline), rodeo contests or as a result of 

participating in any professional, semi-professional or other non-recreational sports 

including boating, motorcycling, skiing, riding all-terrain vehicles or dirt-bikes, 

snowmobiling or go-carting. 

27. Injuries or Sicknesses resulting from participation in interscholastic, intercollegiate or 

organized competitive sports. 

28. Injury resulting from being under the influence of or due wholly or partly to the effects of 

alcohol or drugs, other than drugs taken in accordance with treatment prescribed by a 

Doctor, but not for the treatment of Substance Abuse. 

29. Willfully self-inflicted Injury or Sickness. 

30. Immunizations and Routine Physical Exams, except as expressly covered under this 

certificate or under a Rider attached to this certificate. 

31. Services received for any condition caused by a Covered Person’s commission of or 

attempt to commit a felony or to which a contributing cause was the Covered Person 

being engaged in an illegal occupation. 

32. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or 

music therapy, holistic care of any nature, massage and kinestherapy. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 92 of 166
HCCL STMM 102 CA 20

33. Any services performed or supplies provided by a member of the Insured’s Immediate 

Family. 

34. Orthoptics and visual eye training. 

35. Services or supplies which are not included as Eligible Expenses as described herein. 

36. Care, treatment or supplies for the feet: orthopedic shoes, orthopedic prescription 

devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable 

or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or 

toenails. 

37. Care and treatment for hair loss including wigs, hair transplants or any drug that 

promises hair growth, whether or not prescribed by a Doctor. 

38. Treatment of sleep disorders. 

39. Hypnotherapy when used to treat conditions that are not recognized as Mental or 

Nervous Disorders by the American Psychiatric Association, and biofeedback, and nonmedical self-care or self-help programs. 

40. Any services or supplies in connection with cigarette smoking cessation. 

41. Exercise programs, whether or not prescribed or recommended by a Doctor. 

42. Treatment required as a result of complications or consequences of a treatment or 

condition not covered under this certificate. 

43. Charges for travel or accommodations, except as expressly provided for local 

ambulance. 

44. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or 

radioactive material(s). 

45. Organ or Tissue Transplants or related services. 

46. Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea, 

sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic 

conditions of skin, nevus. 

47. Services received or supplies purchased outside the United States, its territories or 

possessions, or Canada. 

48. Treatment for or related to any congenital condition, except as it relates to a newborn or 

adopted child added as a Covered Person to this certificate. 

49. Spinal manipulation or adjustment. 

50. Sclerotherapy for veins of the extremities. 

51. Expenses during the first 6 months after the Effective Date of coverage for a Covered 

Person for the following (subject to all other coverage provisions, including but not 

limited to the Pre-existing Condition exclusion): 

A. Total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis 

of carcinoma; 

B . T o n s i l l e c t o m y ; 

C . A d e n o i d e c t o m y ; 

D. Repair of deviated nasal septum or any type of surgery involving the sinus; 

E . M y r i n g o t o m y ; 

F . T y m p a n o t o m y ; 

G . H e r n i o r r h a p h y ; o r 

H. Ch o le c y s t e c t o m y. 

52. Chronic fatigue or pain disorders. 

53. Treatment or diagnosis of allergies, except for emergency treatment of allergic reactions. 

54. Treatment, medication or hormones to stimulate growth, or treatment of learning 

disorders, disabilities, developmental delays or deficiencies, including therapy. 

55. Kidney or end stage renal disease. 

56. Joint replacement or other treatment of joints, spine, bones or connective tissue 

including tendons, ligaments and cartilage, unless related to a covered Injury. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 93 of 166
HCCL STMM 102 CA 21

57. Expenses resulting from a declared or undeclared war, or from voluntary participation in 

a riot or insurrection. 

58. Expenses incurred by a Covered Person while on active duty in the armed forces. Upon 

written notice to Us of entry into such active duty, the unused premium will be returned 

to the Covered Person on a pro-rated basis. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 94 of 166
HCCL STMM 102 CA 22

PART VII – COORDINATION OF BENEFITS (COB) 

Some people have health care coverage through more than one medical insurance plan at the 

same time. COB allows these plans to work together so the total amount of all benefits will 

never be more than 100 percent of the allowable expenses during any coverage year. This 

helps to hold down the costs of health coverage. 

COB does not apply to life insurance or accidental death and dismemberment benefits. 

The term “plan” applies separately to each policy, contract agreement or other arrangements for 

benefits or services. The term “plan” also applies separately to that part of any policy, contract, 

agreement or other arrangements for benefits or services that coordinates its benefits with other 

plans and to that part that does not. 

When a plan provides benefits in the form of services rather than cash payment the reasonable 

cash value of each service rendered will be considered to be both: (1) an allowable expense; 

and (2) a benefit paid. 

Definitions. “Plan” – means any of the following which provides benefits or services for 

medical expenses: 

1. Any group insurance or group-type coverage, whether insured or uninsured. This 

includes prepayment, group practice, or individual practice coverage. 

2. Any federal, state or local governmental programs, or coverage required or provided by 

law. This does not include a state plan under Medicaid (Title XIX, Grants to States for 

Medical Assistance Programs, of the United States Social Security Act, as amended 

from time to time.) 

Each contract or other arrangement for coverage under the above paragraphs is a separate 

plan. Also, if an arrangement has two parts and COB rules apply to one of the two, each of the 

parts is construed to mean a separate Plan. 

The term "plan" does not include: 

1. Individual or family insurance or subscriber contracts; 

2 Individual or family coverage through Health Maintenance Organizations (HMOs); 

3. Individual or family coverage under other prepayment, group practice and individual 

practice plans; 

4. School accident-type coverages. (These contracts cover students for accidents only, 

including athletic injuries, either on a twenty-four hour basis or on a to-and-from school 

basis); 

5. Group or group-type hospital indemnity benefits of $100 per day or less; 

6. Medicare Supplement policies; 

7. A state plan under Medicaid. 

“Primary Plan (Primary)” – means the Plan which determines its benefits before those of the 

other Plan. When there are more than two (2) Plans, This Plan may be Primary as to one and 

Secondary as to another. 

“Secondary Plan (Secondary)” – means the Plan which determines its benefits after those of 

the other Plan. When there are more than 2 Plans, This Plan may be Secondary as to one and 

Primary as to another. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 95 of 166
HCCL STMM 102 CA 23

“This Plan” – means the benefits provided under this group policy. 

Effect on Benefits. Plans use COB to decide which plan should pay first for a covered 

expense. If the Primary Plan’s payment is less than the charge for the allowable expense, then 

the Secondary Plan will apply its benefit payment to the balance. 

The following rules will be used to establish the order of benefit determination: 

 1. A plan which does not have a COB provision will always be the Primary Plan. 

 2. The benefits of a plan which covers the person on whose expenses the claim is based 

as other than a dependent will be determined before the benefits of a plan which covers 

the person as a dependent. However, if the person is also a Medicare beneficiary, and if 

the rule established under the Social Security Act of 1965, as amended, makes 

Medicare secondary to the plan covering the person as a dependent of an active 

employee, the order of benefit determination is: 

A. First, benefits of a plan covering persons as an employee, member, or 

subscriber. 

B. Second, benefits of a plan of an active worker covering persons as a dependent. 

C. Third, Medicare benefits. 

 3. The benefits of a plan that covers a person for whom a claim is made as a dependent 

child will be determined under the following rules:

A. When the parents are married: the benefits of a plan which covers the child as a 

dependent of the parent whose birthday anniversary occurs earlier in the 

calendar year will be determined before the benefits of a plan which covers the 

child as a dependent of the parent whose birthday anniversary occurs later in the 

calendar year. 

B. If both parents have the same birthday the benefits of the plan that covered the 

parent longer are determined before those of the plan that covered the other 

parent for a shorter period of time. 

C. If the plans do not agree on the order of benefit rules because the other plan 

does not have the rule described in this section, but has a rule based upon the 

gender of the parent, the rule in the other plan will determine the order of 

benefits. 

D. When the parents are separated or divorced and the parent with custody has not 

remarried the benefits of a plan which covers the child as a dependent of the 

parent with custody of the child will be determined before the benefits of a plan 

which covers the child as a dependent of the parent without custody. 

E. When the parents are divorced and the parent who has custody of the child has 

remarried: (a) the benefits of a plan which covers the child as a dependent of the 

parent with custody will be determined before the benefits of a plan which covers 

the child as a dependent of the step-parent; and (b) the benefits of a plan that 

covers the child as a dependent of the step-parent will be determined before the 

benefits of a plan that covers the child as a dependent of the parent without 

custody. 

F. Despite (2) and (3) above, if there is a court decree which would otherwise 

establish financial responsibility for the medical, dental or other health care 

expenses with respect to the child, the benefit payment of a plan which covers 

the child as a dependent of the parent with such financial responsibility will be 

determined before the benefit payment of any other plan that covers the child as 

a dependent child. 

 4. The benefits of a plan that covers a person as a primary insured who is neither laid off 

nor retired, or as that primary insured’s dependent, are determined before those of a 

plan that covers that person as a laid off or retired primary insured or as that primary 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 96 of 166
HCCL STMM 102 CA 24

insured’s dependent. This rule will not apply if the other plan does not have this rule and 

if, as a result, the plans do not agree on the order of benefits. 

5. If a person whose coverage is provided under a right of continuation pursuant to federal 

or state law is covered under another plan, the following will be the order of benefit 

determination: 

A. First, the benefits of a plan covering the person as an employee, member, or 

subscriber (or as that person’s dependent); 

B. Second, the benefits under the continuation coverage. If the other plan does not 

have the rule described above and if, as a result, the plans do not agree on the 

order of benefits, this rule is ignored. 

6. When rules 2 through 5 do not establish an order of benefit determination the benefits of 

a plan which has covered the person on whose expenses the claim is based for the 

longer period of time will be determined before the benefits of a plan which has covered 

the person the shorter period of time. 

Facility of Payment. If another plan makes a benefit payment that should have been made by 

us we have the right to pay the other plan any amount we deem necessary to satisfy our 

obligation under these COB rules. 

Right of Recovery. If the amount of our benefit payment is more than the amount needed to 

satisfy our obligation under these COB rules, we have the right to recover the excess amount 

from: (A) any persons to or for whom, or with respect to whom, the payments were made; (B) 

any insurance companies; or (C) any other organizations. 

Right to Receive and Release Necessary Information. In order to carry out these COB rules: 

1. We have the right, without the consent of or notice to any person, to exchange 

information with any person, insurance company or organization, as we deem 

necessary; and 

2. Any person claiming benefits under this plan must give us any information necessary to 

carry out this provision. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 97 of 166
HCCL STMM 102 CA 25

PART VIII - CLAIM PROVISIONS 

Notice of Claim: Written notice of claim must be given within 31 days after a covered loss 

begins or as soon as is reasonably possible. The notice must be given to the Company named 

on the Schedule of Benefits. Notice should include information that identifies the claimant and 

the policy. 

Claim Forms: When the Company receives notice of claim, forms for filing proof of loss will be 

sent to the claimant. If claim forms are not supplied within 15 days, a claimant can give proof as 

follows: 

1 . I n w r i t i n g ; 

2 . Setting forth the nature and extent of the loss; and 

3 . Within the time stated in the Proof of Loss provision. 

Proof of Loss: Written proof of loss must be given to the Company within 90 days after the loss 

begins. We will not deny nor reduce any claim if it was not reasonably possible to give proof of 

loss in the time required. In any event, proof must be given to the Company within one year 

after it is due unless the Insured is legally incapable of doing so. 

Time of Payment of Claim: Benefits for loss covered by the policy will be paid as soon as we 

receive proper written proof of such loss, but no later than 30 working days after We receive 

Proof of Loss. 

Payment of Claims: All benefits will be paid to the Insured, if living, unless an Assignment of 

Benefits has been requested by the Insured. Any other benefits due and unpaid at the Insured’s 

death will be paid to the Insured’s estate. If a benefit is to be paid to the Insured’s estate, or to 

an Insured or beneficiary who is not competent to give a valid release, the Company may pay 

up to $1,000.00 of such benefit to one of the Insured’s relatives who is deemed by the Company 

to be justly entitled to it. Such payment, made in good faith, fully discharges the Company to 

the extent of the payment. 

Physical Examination: At our expense, we may have a person claiming benefits examined as 

often as reasonably necessary while the claim is pending. 

Legal Action: No legal action may be brought to recover on the policy before 60 days after 

written proof of loss has been furnished as required by the policy. No such action may be 

brought after three years from the time written proof of loss is required to be furnished. 

Third Party Liability: No benefits are payable for any Sickness, Injury, or other condition for which 

a third party may be liable or legally responsible by reason of negligence, an intentional act, or 

breach of any legal obligation on the part of such third party. Nevertheless, the Company will 

advance the benefits of this policy to the Insured subject to the following: 

1. The Insured agrees to advise Us, in writing, within 60 days of any Covered Person’s 

claim against the third party and to take such action, provide such information and 

assistance, and execute such paper as We may require to facilitate enforcement of the 

claim. The Insured and Covered Person also agree to take no action that may prejudice 

Our rights or interests under this policy. Failure to provide notice of a claim or to 

cooperate with Us, or actions that prejudice Our rights or interests, will be material 

breach of this policy and will result in the Insured being personally responsible for 

reimbursing Us. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 98 of 166
HCCL STMM 102 CA 26

2. We will automatically have a lien, to the extent of benefits advanced, upon any recovery 

that any Covered Person receives from the third party, the third party’s insurer, or the 

third party’s guarantor. Recovery may be by settlement, judgment or otherwise. The 

lien will be in the amount of benefits paid by Us under this policy for the treatment of the 

Sickness, disease, Injury or condition for which the third party is liable. 

Independent Medical Review: A Covered Person, or a representative acting on his or her 

behalf, has the right to request an independent medical review whenever healthcare services 

have been denied, modified or delayed by Us, if the decision was based in whole or in part on a 

finding that the proposed health care services are not medically necessary. A doctor, or other 

health care provider, may assist in seeking an independent medical review and may advocate 

on such Covered Person's behalf. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 99 of 166
HCCL STMM 102 CA 27

PART IX – GENERAL PROVISIONS 

Time Limit on Certain Defenses: The validity of coverage issued under the Policy with respect 

to an Insured or his Eligible Dependents may not be contested after three years from each 

certificate’s effective date, except for nonpayment of premiums. 

Misstatement of Age: If the age of any Covered Person is incorrectly stated, we will make a fair 

adjustment of the premiums, benefits or both. The adjustment will be based on the premiums 

and benefits that would have been payable had we known the correct information. 

Not in Lieu of Workers’ Compensation: The policy is not in lieu of and does not affect 

requirements for coverage under Workers’ Compensation laws. 

Pronouns: Whenever a personal pronoun in the masculine gender is used, it will be deemed to 

include the feminine also, unless the context clearly indicates to the contrary. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 100 of 166
HCCL STMM 102 CA 28

PART X – SCHEDULE OF BENEFITS 

INSURED INFORMATION: 

Name: 

Policy Effective Date: 

COVERAGE PERIOD: 

ELIGIBILE DEPENDENTS COVERED

COVERAGE AND BENEFIT AMOUNTS: 

Deductible per Covered Person per 

Coverage Period. Maximum of 3 

Deductibles per family per Coverage 

Period. 

An additional Deductible of $250 per visit 

will be applied to charges for use of 

emergency room in the event of Sickness 

unless the Covered Person is directly 

admitted as an Inpatient for further 

treatment. 

Coinsurance During a Coverage Period, the Company 

will pay of the next $5,000 of 

Eligible Expenses after the Deductible, 

then 100% of Eligible Expenses to the 

Overall Maximum Limit. 

Urgent Care Center For each visit, the Covered Person shall be 

responsible for a $50 co-payment, after 

which Coinsurance will apply. Not subject 

to Deductible 

Hospital Room and Board Average Semi-private room rate, including 

nursing services.

Local Ambulance Injury: Usual and Customary charges to a

Maximum of $250 per trip, when related to 

a covered Injury. 

Sickness: Usual and Customary charges to 

a maximum of $250 per trip, when covered 

Sickness results in hospitalization as 

Inpatient 

Intensive Care Unit Usual and Customary charges 

Physical Therapy $50 Maximum per visit per day 

Home Health Care Maximum 1 visit per day. Maximum of 40 

visits during a Coverage Period 

Extended Care Facility Not to exceed a daily rate of $150 nor a 

maximum of 60 days 

80% MOHOMMED AZAD 6 Months 12-09-2015 2500

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 101 of 166
HCCL STMM 102 CA 29

All Other Eligible Medical Expenses Usual and Customary charges 

Penalty for Failure to Pre-certify 50% of Eligible Medical Expenses 

Overall Maximum Limit per Coverage 

Period 

$2,000,000

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 102 of 166
Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 103 of 166
Case No.: 4:17-cv-00618-PJH

MANUAL FILING NOTIFICATION

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

DOCUMENT PREPARED

ON RECYCLED PAPER

GERARD G. PECHT (Admitted Pro Hac Vice)

gerard.pecht@nortonrosefulbright.com

NORTON ROSE FULBRIGHT US LLP

1301 McKinney, Suite 5100

Houston, Texas 77010-3095

Telephone: (713) 651-5151

Facsimile: (713) 651-5246

M. SCOTT INCERTO (Admitted Pro Hac Vice)

scott.incerto@nortonrosefulbright.com

NORTON ROSE FULBRIGHT US LLP

98 San Jacinto Boulevard, Suite 1100

Austin, Texas 78701-4255

Telephone: (512) 474-5201

Facsimile: (512) 536-4598

JOSHUA D. LICHTMAN (SBN 176143)

joshua.lichtman@nortonrosefulbright.com

MICHELLE L. MELLO (SBN 288081)

michelle.mello@nortonrosefulbright.com

NORTON ROSE FULBRIGHT US LLP

555 South Flower Street, Forty-First Floor

Los Angeles, California 90071

Telephone: (213) 892-9200

Facsimile: (213) 892-9494

Attorneys for Defendants

HCC LIFE INSURANCE COMPANY and HCC 

MEDICAL INSURANCE SERVICES, LLC 

(erroneously sued as TOKIO MARINE HCC –

MEDICAL INSURANCE SERVICES GROUP) 

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA – OAKLAND DIVISION

MOHAMMED AZAD and DANIELLE 

BUCKLEY, on behalf of themselves and all 

others similarly situated,

Plaintiffs,

v.

TOKIO MARINE HCC – MEDICAL 

INSURANCE SERVICES GROUP, HEALTH 

INSURANCE INNOVATIONS, INC., HCC 

LIFE INSURANCE COMPANY, and 

CONSUMER BENEFITS OF AMERICA,

Defendants.

Case No.: 4:17-cv-00618-PJH

MANUAL FILING NOTIFICATION

Date: May 24, 2017

Time: 9:00 a.m.

Ctrm : 3

Complaint Filed: February 7, 2017

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 104 of 166
- 1 - Case No.: 4:17-cv-00618-PJH

MANUAL FILING NOTIFICATION

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

DOCUMENT PREPARED

ON RECYCLED PAPER

Regarding: EXHIBIT 14 to the DECLARATION OF JON PADGETT

This filing is in paper or physical form only, and is being maintained in the case file in the 

Clerk’s office. If you are a participant on this case, this filing will be served in hard-copy shortly. 

For information on retrieving this filing directly from the court, please see the court’s main 

website at http://www.cand.uscourts.gov under Frequently Asked Questions (FAQ). 

This filing was not efiled for the following reason(s):

___ Unable to Scan Documents

___ Physical Object (please describe): _________________________________

_X_ Non-Graphic/Text Computer File (audio, video, etc.) on CD or other media

___ Item Under Seal in Criminal Case

___ Conformance with the Judicial Conference Privacy Policy (General Order 53)

___ Other (please describe): __________________________________________

Dated: April 14, 2017 GERARD G. PECHT 

M. SCOTT INCERTO 

JOSHUA D. LICHTMAN

MICHELLE L. MELLO

NORTON ROSE FULBRIGHT US LLP

By /s/ Joshua D. Lichtman __

JOSHUA D. LICHTMAN

Attorneys for Defendants

HCC LIFE INSURANCE COMPANY and 

HCC MEDICAL INSURANCE SERVICES, 

LLC (erroneously sued as TOKIO MARINE 

HCC – MEDICAL INSURANCE SERVICES 

GROUP) 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 105 of 166
EXHIBIT 15 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 106 of 166
Steven Buckley

 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 107 of 166
THANK YOU for your purchase of HCC Life Insurance 

Company’s Short Term Medical coverage. Please review 

your coverage and application carefully. A few important 

reminders regarding your coverage are outlined below:

The insurance contains the lifetime maximum, 

co-insurance and deductible amounts that you selected 

at the time of application. The coverage contains 

exclusions for specific conditions and treatments as well 

as a pre-existing condition exclusion. The insurance does 

not pay for routine physicals or immunizations unless 

required by state law. In addition, hernia operations, gall 

bladder removal and other selected surgical procedures 

are not covered for the first 6 months the coverage is in 

force. HCC Life Insurance Company, in no event, will 

provide benefits in excess of those specified in the 

insurance contract. This insurance is not subject to 

guaranteed issuance or renewal.

 

Getting Medical Treatment:

Show your ID card to the medical attendant.

Pay the deductible or copay (if applicable).

 to us. 

After the visit, you will need to submit a 

Claimant's Statement.

Filing a Medical Claim:

Submit original, itemized bills, and any 

 payment receipts, and claim form

 service.hccmis.com

A copy of a Claims Statement can be 

 obtained by clicking:

 http://www.hccmis.com/downloads

Client Zone 

https://zone.hccmis.com/clientzone/

Contact Us 

service.hccmis.com

Cancellations (after Free Look period):

Should you wish to cancel, please send a request to orders@hccmis.com *Note - the request must include your 

 policy number and needs to come from the email address on file used to purchase the policy.

If paying by monthly installments, a request needs to be submitted prior to your next installment date.

 can be processed.

x

Free Look Provision:

Your insurance contract contains a free look period which allows you to cancel the coverage for any reason.

 Coverage. All cancellation requests should be sent to orders@hccmis.com

Pre-Existing Conditions:

Charges resulting directly or indirectly from any pre-existing condition are excluded from this insurance.

If you had an illness, and injury or condition at the time of purchase that you intended to have covered under 

 this insurance, it will likely not be covered and you should consider using the free look provision. 

Please refer to the limits set forth in your Short Term Medical insurance provided at the time of purchase.

HCC Medical Insurance Services, LLC 

Important:

Act (PPACA). It does not contain many of the coverages required by PPACA. Depending on the time of year and 

individual circumstances, you can purchase PPACA compliant individual health insurance plans from your state’s 

Health Insurance Marketplace.

!

Short-Term Medical STM ADMINISTERED BY HCC MEDICAL INSURANCE SERVICES

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 108 of 166
 

Payment Receipt 

For Certi"cate: 

Paid By: 

Payment Type: 

Number: 

Amount: 

Date Paid: 

Credit Card Payments Only 

Expiration Date: 

Trans. Code: 

Auth. Code: 

Steven Buckley

VISA

xxxxxxxxxxxx7403

$675.55

3/31/2016

1/19

1390213746

06054C

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 109 of 166
 Covered Dependents: 

Primary Insured: 

Certificate #: 

Plan #: 

Effective Date: 

POSSESSION OF THIS CARD DOES NOT GUARANTEE COVERAGE 

| 

| 

F 

O 

L 

D 

| 

|

• For general questions 

 regarding Eligibility / Benefits / 

 Claims, please call: 

 1-800-605-2282 or 

 1-317-262-2132

• Mail itemized bills including 

 diagnosis to: 

 

 HCCMIS Claims Department 

 Box No. 2005 

 Farmington Hills, MI 

 48333-2005 

• Claims may be submitted 

 electronically using 

 Payer ID: HCCMI

 Covered Dependents: 

Primary Insured: 

Certificate #: 

Plan #: 

Effective Date: 

POSSESSION OF THIS CARD DOES NOT GUARANTEE COVERAGE 

| 

| 

F 

O 

L 

D 

| 

|

• For general questions 

regarding Eligibility / Benefits / 

Claims, please call: 

 1-800-605-2282 or 

 1-317-262-2132

• Mail itemized bills including 

 diagnosis to: 

 

 HCCMIS Claims Department 

 Box No. 2005 

 Farmington Hills, MI 

 48333-2005 

• Claims may be submitted 

 electronically using 

 Payer ID: HCCMI

Danielle Buckley

Steven Buckley

STM600-1

4/1/2016

Danielle Buckley

Steven Buckley

STM600-1

4/1/2016

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 110 of 166
CBA

Consumer Benefits

of America

0/"OX$ENVER#/

A  N O T 
 F O R 
 P R O F I T  C O R P O R A T I O N





'

0

-

%

.FNCFST$BMMUPMMGSFFPSHPUP

XXX3Y4BWJOHT1MVTDPNUPMPDBUFBQIBSNBDZ

QSPWJEFS

1IBSNBDJTUT5IF3Y1$/
3Y(31BOEGVMMNFNCFS

*%NVTUCFTVCNJUUFEPOMJOFUPQSPDFTTDMBJNTGPSUIJT

QSPHSBN"MXBZTVTFBOQFSTPODPEFUPQSPDFTT

DMBJNTGPSUIJTQSPHSBN'PSJOGPSNBUJPO
DPOUBDUVTBU



CBA

)$

.!-%

28"). 

280#.!$6

28'2028#"!

)335%2	

1IBSNBDZ%JTDPVOU$BSE

5IJTQSPHSBNJTOPUJOTVSBODF

%FBS/FX.FNCFS


"TBDPOTVNFSBXBSFOFTTJOJUJBUJWF
$POTVNFS#FOFmUTPG"NFSJDBIBTCSPVHIUZPVUIJTBEEJUJPOBMEJTDPVOUQSPHSBNPO

OFXPSSFmMMQSFTDSJQUJPONFEJDBUJPOTBWBJMBCMFGSPNPWFS
QBSUJDJQBUJOHSFUBJMQIBSNBDJFTOBUJPOXJEFPSCZNBJM

TFSWJDF	/PDPTUGPSUIJT3YQSPHSBN


3Y4BWJOHT1MVT4.

6TFZPVS3Y4BWJOHT1MVTESVHEJTDPVOUDBSE


 5BLFZPVSQSFTDSJQUJPO	T
JOUPBOZPGUIFPWFS
QBSUJDJQBUJOHQIBSNBDJFTTVDIBT8BMHSFFOT
$74BOE3JUF"JE


 1SFTFOUZPVS3Y4BWJOHT1MVTDBSEUPUIFQIBSNBDJTUBMPOHXJUIZPVSQSFTDSJQUJPO	T



 1BZUIFQIBSNBDZ

*UTTJNQMZBHSFBUXBZUPTBWFNPOFZPOQSFTDSJQUJPOESVHT"GUFSXPSLJOHDMPTFMZXJUIQIBSNBDJFTBOEESVH

NBOVGBDUVSFST
XFWFOFHPUJBUFEMPXFSQSJDFTGPSUIPVTBOETPGNFEJDBUJPOTBOETIBSFUIFTFTBWJOHTXJUIZPV

5PTFFIPXNVDIZPVXPVMETBWFPOZPVSPXOQSFTDSJQUJPONFEJDBUJPOT
DBMMUPMMGSFF
WJTJU

XXX394BWJOHT1MVTDPNPSBTLBUZPVSMPDBMQIBSNBDZ:PVNBZSFDFJWFFWFOHSFBUFSTBWJOHToVQUPQFSDFOU

oJGZPVSQSFTDSJQUJPOTBSFmMMFEUISPVHIPVSNBJMTFSWJDF

6TFPOFDBSEGPSUIFFOUJSFIPVTFIPMEoFWFOQFUT

7JTJUVTPOMJOFUPEBZUPTFFIPXNVDIZPVDBOTBWF

XXX394BWJOHT1MVTDPN

5IJTQSPHSBNJTOPUJOTVSBODF4BWJOHTBSFPOMZBWBJMBCMFBUQBSUJDJQBUJOHQIBSNBDJFT

Steven Buckley

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 111 of 166
$IPJDF

.FNCFS

#FOFmU

(VJEF

CBA

Consumer Benefits

of America

10#PY

%FOWFS
$0

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 112 of 166


%FBS/FX.FNCFS


8FMDPNFUP$POTVNFS#FOFmUTPG"NFSJDB	$#"

BO"TTPDJBUJPOFTUBCMJTIFEUPTFSWF:06
UIFDPOTVNFS

5IJT.FNCFSTIJQ(VJEFBOE*%$BSEDPOUBJOJNQPSUBOUQIPOFBOE*%OVNCFSTOFDFTTBSZGPSiFBTZBDDFTTwXIFO

VUJMJ[JOHUIFTBWJOHTBOETFSWJDFTXJUIJOUIJTHVJEFBWBJMBCMFUPZPVBOEZPVSGBNJMZ

4JODFJUTJODFQUJPO
$#"IBTBMXBZTCFFOFYUSFNFMZDPOTDJFOUJPVTJOJUTFõPSUTUPQSPWJEFRVBMJUZTBWJOHTBOETFS

WJDFGPSJUTNFNCFST0VSFYQFDUBUJPOTBSFUIBUZPVXJMMCFFYUSFNFMZQMFBTFE

3Y4BWJOHT1MVT4.

"TBDPOTVNFSBXBSFOFTTJOJUJBUJWF
$POTVNFS#FOFmUTPG"NFSJDBIBTCSPVHIUZPVUIJTBEEJUJPOBMEJTDPVOUQSPHSBNPOOFX

PSSFmMMQSFTDSJQUJPONFEJDBUJPOTBWBJMBCMFGSPNPWFS
QBSUJDJQBUJOHSFUBJMQIBSNBDJFTOBUJPOXJEFPSCZNBJMTFSWJDF	/P

DPTUGPSUIJT3YQSPHSBN


6TFZPVS3Y4BWJOHT1MVTESVHEJTDPVOUDBSE


 5BLFZPVSQSFTDSJQUJPO	T
JOUPBOZPGUIFPWFS
QBSUJDJQBUJOHQIBSNBDJFTTVDIBT

 8BMHSFFOT
$74BOE3JUF"JE


 1SFTFOUZPVS3Y4BWJOHT1MVTDBSEUPUIFQIBSNBDJTUBMPOHXJUIZPVSQSFTDSJQUJPO	T



 1BZUIFQIBSNBDZ

*UTTJNQMZBHSFBUXBZUPTBWFNPOFZPOQSFTDSJQUJPOESVHT"GUFSXPSLJOHDMPTFMZXJUIQIBSNBDJFTBOEESVHNBOVGBD

UVSFST
XFWFOFHPUJBUFEMPXFSQSJDFTGPSUIPVTBOETPGNFEJDBUJPOTBOETIBSFUIFTFTBWJOHTXJUIZPV

5PTFFIPXNVDIZPVXPVMETBWFPOZPVSPXOQSFTDSJQUJPONFEJDBUJPOT
DBMMUPMMGSFF
WJTJU

XXX394BWJOHT1MVTDPNPSBTLBUZPVSMPDBMQIBSNBDZ:PVNBZSFDFJWFFWFOHSFBUFSTBWJOHToVQUPQFSDFOUoJG

ZPVSQSFTDSJQUJPOTBSFmMMFEUISPVHIPVSNBJMTFSWJDF

6TFPOFDBSEGPSUIFFOUJSFIPVTFIPMEoFWFOQFUT

4BWFBOBWFSBHFPGQFSDFOU7JTJUVTPOMJOFUPEBZUPTFFIPXNVDIZPVDBOTBWF

XXX394BWJOHT1MVTDPN

5IJTJTOPUJOTVSBODF%JTDPVOUTBSFPOMZBWBJMBCMFBUQBSUJDJQBUJOHQIBSNBDJFT4BWJOHTNBZWBSZCZESVHBOECZ

QIBSNBDZ4BWJOHTBSFCBTFEPOBDUVBMESVHQVSDIBTFTGPSBMMESVHEJTDPVOUDBSEQSPHSBNTBENJOJTUFSFECZ

$BSFNBSL5IFQSPHSBNBENJOJTUSBUPSNBZPCUBJOGFFTPSSFCBUFTGSPNNBOVGBDUVSFTBOEPSQIBSNBDJFTCBTFEPOZPVS

QSFTDSJQUJPOESVHQVSDIBTFT5IFTFGFFTPSSFCBUFTNBZCFSFUBJOFECZUIFQSPHSBNBENJOJTUSBUPSPSTIBSFEXJUIZPV

BOEPSZPVSQIBSNBDZ#ZVTJOHUIJTDBSE
ZPVBHSFFUIBUZPVBSFSFTQPOTJCMFGPSQBZJOHUIFFOUJSFQSFTDSJQUJPODPTUPG

UIFNFEJDBUJPOBGUFSUIFBQQMJDBUJPOPGBOZBQQMJDBCMFEJTDPVOU1SFTDSJQUJPODMBJNTUISPVHIUIJTQSPHSBNXJMMOPUCF

FMJHJCMFGPSSFJNCVSTFNFOUUISPVHI.FEJDBJE
.FEJDBSFPSBOZPUIFSHPWFSONFOUQSPHSBN

3Y4BWJOHT1MVT4.'SFRVFOUMZ"TLFE2VFTUJPOT	'"2T


(FOFSBM2VFTUJPOT

%PFTFWFSZPOFJONZGBNJMZOFFEBOJOEJWJEVBMDBSE 

/P&WFSZPOFJOUIFGBNJMZNBZVTFUIFTBNFDBSEJGEFTJSFE

$BO*VTFUIJTDBSEUPHFUEJTDPVOUTPONZQFUTNFEJDBUJPOT 

:FT
JGZPVSQFUIBTCFFOQSFTDSJCFEBNFEJDBUJPO
ZPVNBZSFDFJWFBEJTDPVOUPOUIFNFEJDBUJPOCZUBLJOHUIFQSF

TDSJQUJPOUPBQBSUJDJQBUJOHSFUBJMQIBSNBDZ

*KVTUSFDFJWFENZDBSE$BO*VTFJUSJHIUBXBZ 

:FT
KVTUVTFZPVSDBSEUPTUBSUTBWJOHJNNFEJBUFMZ1SFTFOUZPVSQSFTDSJQUJPOEJTDPVOUDBSEBUBQBSUJDJQBUJOHSFUBJMQIBS

NBDZXIFOZPVmMMPSSFmMMZPVSQSFTDSJQUJPOT

$BO*VTFNZDBSEUPHFUEJTDPVOUTPOPWFSUIFDPVOUFSQSPEVDUTBOEOPOQSFTDSJQUJPONFEJDBUJPOT 

/PUVTVBMMZ)PXFWFS
EJTDPVOUTBSFBWBJMBCMFGPSNBOZEJBCFUJDTVQQMJFT

)PXJTUIJTQSFTDSJQUJPOEJTDPVOUQSPHSBNEJõFSFOUGSPNUSBEJUJPOBMQSFTDSJQUJPOJOTVSBODF 

5IJTQSPHSBNJTOPUJOTVSBODFJUJTBQSFTDSJQUJPOESVHEJTDPVOUQSPHSBN5IFDBSEQSPWJEFTJNNFEJBUFEJTDPVOUT

BUUIFQIBSNBDZ6QPOQSFTFOUJOHZPVSDBSEUPUIFQIBSNBDJTU
ZPVXJMMQBZUIFMPXFSPGBEJTDPVOUFEQSJDFPSUIF



Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 113 of 166


QIBSNBDZTSFHVMBSSFUBJMQSJDF5IFSFBSFOPDMBJNGPSNTUPmMMPVUBOEOPMJNJUUPUIFOVNCFSPGUJNFTZPVDBOVTFUIF

DBSE5IFTFEJTDPVOUTBSFBWBJMBCMFPOMZBUQBSUJDJQBUJOHQIBSNBDJFT

$BO*VTFNZQSFTDSJQUJPOEJTDPVOUDBSEXJUINZDVSSFOUJOTVSBODFCFOFmUUPSFEVDFNZDPTUT 

:PVSDBSEDBOOPUCFVTFEJODPOKVODUJPOXJUIPUIFSJOTVSBODF)PXFWFS
ZPVBSFBCMFUPVTFZPVSDBSEUPQVSDIBTF

QSFTDSJQUJPOTUIBUBSFOPUDPWFSFECZUIFTFQMBOT

"CPVUUIF$BSFNBSL.BJM4FSWJDF1SPHSBN

8IBUJTNBJMTFSWJDF 

"TBQBSUJDJQBOUPGUIF3Y4BWJOHT1MVTQSPHSBNZPVBSFBVUPNBUJDBMMZFMJHJCMFGPSUIF$BSFNBSL.BJM4FSWJDFQSPHSBN

8JUIUIJTQSPHSBNZPVDBOQVSDIBTFVQUPBEBZTVQQMZPGTFMFDU
MPOHUFSN
NBJOUFOBODFNFEJDBUJPOTGSPNUIFNBJM

TFSWJDFQIBSNBDZGPSBmYFEQSJDF*UTFBTZUPHFUTUBSUFEXJUINBJMTFSWJDFKVTUTFOEJOBNBJMTFSWJDFPSEFSGPSNBMPOH

XJUIZPVSPSJHJOBMQSFTDSJQUJPO
UP$BSFNBSL'PSBMJTUPGNFEJDBUJPOTBWBJMBCMF
BOEUPSFDFJWFBOPSEFSGPSN
QMFBTFWJTJU

XXX394BWJOHT1MVTDPNPSDBMMUPMMGSFF

"CPVU4QFDJBMUZ1IBSNBDZ

8IBUJTTQFDJBMUZQIBSNBDZBOEXIBULJOETPGTFSWJDFTEPUIFZPõFS 

4QFDJBMUZQIBSNBDZPõFSTEFMJWFSZPGJOKFDUBCMFBOETFMFDUPSBMTQFDJBMUZNFEJDBUJPOBOETVQQMJFTUPUIFMPDBUJPOPG

ZPVSDIPJDF4FSWJDFTJODMVEFEFMJWFSZOPUJmDBUJPOBOESFmMMSFNJOEFSDBMMTUPIFMQZPVTUBZPOZPVSUSFBUNFOUQMBO

:PVMMBMTPSFDFJWFFYQFSUDBSFTFSWJDFTJODMVEJOHDPVOTFMJOH
GPMMPXVQDBSFDBMMT
JOGPSNBUJWFEJTFBTFSFMBUFENBUFSJBMT


BOEBDDFTTUPIFBMUIFYQFSUTIPVSTBEBZ
TFWFOEBZTBXFFL

8IBUESVHTBSFPõFSFEUISPVHITQFDJBMUZQIBSNBDZ 

.FEJDBUJPOTGPSBWBSJFUZPGDISPOJDDPOEJUJPOTJODMVEJOHNVMUJQMFTDMFSPTJT
SIFVNBUPJEBSUISJUJT
DZTUJDmCSPTJT
IFNP

QIJMJB
JOGFSUJMJUZ
JNNVOPMPHJDEJTPSEFST
$SPIOTEJTFBTF
(BVDIFSEJTFBTF
QVMNPOBSZIZQFSUFOTJPO
'BCSZEJTFBTF
.14


CMPPEEZTDSBTJB
HSPXUIIPSNPOFEFmDJFODZ
SFTQJSBUPSZTZODZUJBMWJSVT
IFQBUJUJT$
BOENPSFBSFBWBJMBCMFUISPVHI

UIFTQFDJBMUZQIBSNBDZ

-&("-$"3&"NFSJDB-FHBM"TTJTUBODF1SPHSBN

-&("-$"3&"NFSJDBJTBOJOOPWBUJWFQSPHSBNEFTJHOFEUPQSPWJEF$#"NFNCFSTXJUIFBTZ
DPOGJEFOUJBMBDDFTTUPUIF

MFHBMBTTJTUBODFZPVSFRVJSFJOZPVSCVTJOFTT
QSPGFTTJPOBMBOEQFSTPOBMBGGBJST

5IF"NFSJDBO#BS"TTPDJBUJPOFTUJNBUFTUIBUNJMMJPO"NFSJDBOTIBWFWJSUVBMMZOPBDDFTTUPFWFOUIFNPTUCBTJDPG

MFHBMBTTJTUBODF5IFSFBTPOTGPSUIJTBSFUISFFGPME

t 5IFZEPOPULOPXIPXUPGJOEUIFSJHIUBUUPSOFZ

t 5IFZBSFDPODFSOFEUIBUUIFZDBOOPUBGGPSEUIFDPTUBOE

t 5IFZBSFBGSBJEUPTQFBLXJUIBOBUUPSOFZ

5ISPVHIZPVS-&("-$"3&CFOFGJU
ZPVBSFQSPWJEFEXJUIUIFBCJMJUZUPTPMWFFBDIPGUIFTFDPODFSOT

'SPNUJNFUPUJNF
XFBMMGBDFMFHBMDPODFSOTBOEDIBMMFOHFTUIBUDPVMECFCFUUFSIBOEMFEJGBOBUUPSOFZXFSFDPO

TVMUFE)BWFZPVFWFS

t 5IPVHIUBCPVUXSJUJOHPSSFWJTJOHZPVSXJMM 

t 1VSDIBTFEBIPNFPSBVUPNPCJMF 

t 1VSDIBTFEBEFGFDUJWFQSPEVDUBOECFFOJHOPSFECZUIFNFSDIBOUPSNBOVGBDUVSFS 

t 1BJEBCJMMUIBUZPVLOFXXBTVOGBJS 

t 3FDFJWFEBOVOKVTUUSBGGJDUJDLFU 

t )BEBQSPCMFNXJUIDIJMETVQQPSU
TFQBSBUJPO
WJTJUBUJPO
HVBSEJBOTIJQ
PSEJWPSDF 

t 4JHOFEBMFHBMMZCJOEJOHEPDVNFOUBOECFFOTPSSZMBUFS 

8JUI-&("-$"3&
UIFBTTJTUBODFJTKVTUBQIPOFDBMMBXBZ0WFSPGDBMMFSTUP-&("-$"3&IBWFUIFJSQSPCMFNSF

TPMWFECZQIPOF

-&("-$"3&JTBWBJMBCMFPOBOBUJPOXJEFCBTJTGSPNBNUPQNZPVSMPDBMUJNF
.POEBZUISPVHI'SJEBZ-&("-

$"3&TTFSWJDFTJODMVEF

t )FMQMJOF"GSFFMFHBMiIFMQMJOFwXIJDIBMMPXTZPVUPDBMMBOETQFBLXJUIBOBUUPSOFZUPPCUBJOMFHBMBEWJDF
JOGPSNB

UJPOBOEBOTXFSTUPRVFTUJPOTPSQSPCMFNTSFMBUJOHUPZPVSCVTJOFTT
QSPGFTTJPOBMPSQFSTPOBMNBUUFST5IFSFJTOP

MJNJUUPUIFOVNCFSPGDBMMTPSUIFMFOHUIPGUJNFZPVNBZTQFOEPOUIFUFMFQIPOFXJUIUIFiIFMQMJOFwBUUPSOFZ

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 114 of 166


t 3FGFSSBMT"OZUJNFZPVOFFEMFHBMSFQSFTFOUBUJPO
ZPVXJMMCFQSPWJEFEXJUIUIFOBNFPGPOFPSNPSFBUUPSOFZT

XIPQBSUJDJQBUFXJUI-&("-$"3&BTBiSFGFSSBMwMBXGJSN"MMSFGFSSBMTXJMMCFUPBUUPSOFZTXIPTQFDJBMJ[FJOZPVSBSFB

PGOFFEBOEXIPBSFOFBSZPVSIPNFPSPGGJDFi3FGFSSBMwBUUPSOFZTXJMMQSPWJEFBNJOVUF'3&&JOJUJBMDPOTVMUBUJPO

BOEEJTDPVOUUIFJSTUBOEBSECJMMJOHSBUFGPSBOZMFHBMJTTVFGPSXIJDIZPVDIPPTFUPIJSFUIFN

$POUBDUJOH-&("-$"3&JTBTFBTZBTQJDLJOHVQUIFUFMFQIPOF"OZUJNFZPVIBWFBRVFTUJPO
PSOFFEBSFGFSSBM
BMMZPV

OFFEUPEPJTDBMM-&("-$"3&TUPMMGSFFOVNCFS:PVXJMMTQFBLXJUIBOPQFSBUPSXIPXJMMBTLGPSDFSUBJO

JOGPSNBUJPO"OBUUPSOFZXJMMSFUVSOZPVSDBMMXJUIJOIPVST

5IJT-&("-$"3&"NFSJDBCFOFGJUIBTBOFYDMVTJPOSFMBUJOHUP$POTVNFS#FOFGJUTPG"NFSJDBOBOEBGGJMJBUFT

%JTDPVOU'MPXFSTBOE(JGUT

4BWF8JUI'5%$0.¥

'5%$0.JTUIFQSFNJFSFOBNFJOGMPXFSTBOETQFDJBMUZHJGUT8FVUJMJ[FPOMZUIFGJOFTU'5%¥GMPSJTUTUPEFMJWFSZPVS

GMPSBMBSSBOHFNFOUT
BOEXFPGGFSBDVTUPNFSTBUJTGBDUJPOHVBSBOUFF#FDBVTFPG'5%$0.TWBTUOFUXPSLPGGMPSJTUT
XF

PGGFSTBNFEBZEFMJWFSZUISPVHIPVU$BOBEBBOEUIF6OJUFE4UBUFTBOEPGGFSGMPSBMEFMJWFSZUPNPSFUIBODPVOUSJFT

XPSMEXJEF"OEXJUI'5%$0.TGSFFPOMJOFQFSTPOBMBDDPVOUTFSWJDFT
HJGUHJWJOHIBTOFWFSCFFOFBTJFS0SEFSPOMJOF

BUXXXGUEDPNCVZOFUPSDBMM4&/%'5%BOEBTLGPSQSPNPUJPODPEFBOETBWF

8JUIPWFSGMPSBMBOEOPOGMPSBMJUFNTUPDIPPTFGSPNZPVBSFCPVOEUPGJOETPNFUIJOHUPNBLFTPNFPOFTEBZ

$IPPTFGSPNCSBOEOBNFTQFDJBMUZHJGUTGSPN(IJSBSEFMMJ
.ST'JFMET
#VJME"#FBS
(FWBMJBDPGGFFBOENPSF

4PNBLFTPNFPOFTEBZTQFDJBMXJUI'5%$0.

0SEFSPOMJOFBUXXXGUEDPNCVZOFUPSDBMM

BOEBTLGPSQSPNPUJPODPEFBOETBWF

#VEHFU5SVDL3FOUBM

3FOUB5SVDL'SPNB$PNQBOZ5IBUT8JUI:PVBU&WFSZ5VSO

8IFOJUTUJNFUPNPWFZPVDBOTBWFNPOFZCZEPJOHJUZPVSTFMG/PX#VEHFUDBOTBWFZPVFWFONPSFNPOFZ

8FMM#F"MPOH'PS5IF3JEF

:PVMMIBWFUIFTUSFOHUIPGUIFXPSMETMBSHFTUUSBOTQPSUBUJPOSFTPVSDFTDPNQBOZCBDLJOHZPVXJUIUIFSFOUBMJOEVTUSZT

NPTUDPNQSFIFOTJWFOFUXPSLPGTVQQPSUTFSWJDFTCFOFGJUTMJLFBUPMMGSFFDVTUPNFSTFSWJDFOVNCFS
IPVSFNFS

HFODZSPBETFSWJDF
BOEMJUFSBMMZUIPVTBOETPG#VEHFUEFBMFSTOBUJPOXJEF

'PS3BUFT
-PDBUJPOT3FTFSWBUJPOT

 $BMMPVSOBUJPOBMSFTFSWBUJPODFOUFSBU	


 4JNQMZVTFPVS"TTPDJBUJPO"DDPVOU
UPSFDFJWFBEJTDPVOUPGGUJNF

 BOENJMFBHFSBUFTPOBOZMPDBMPSPOFXBZSFOUBM

 )BWFUIFTFEFUBJMTSFBEZQJDLVQMPDBUJPO	[JQDPEFTBSFIFMQGVMJGUIFFYBDUMPDBUJPOJT

 VOLOPXO

USVDLTJ[FBOEOVNCFSPGEBZTOFFEFE

/PSUI"NFSJDBO7BO-JOFT

4QFDJBMEJTDPVOUTBSFOPXBWBJMBCMFUP#VZJOH/FUXPSLNFNCFSTUISPVHI/PSUI"NFSJDBO7BO-JOFT

"TBNFNCFSZPVSSFDFJWFUIFGPMMPXJOHCBTJDEJTDPVOUTPOJOUFSTUBUFNPWFT

 NJOJNVNCPUUPNMJOFEJTDPVOU	FYDMVEJOHUIJSEQBSUZ
WBMVBUJPOBOETUPSBHF


 EJTDPVOUPOTUPSBHFSFMBUFEOFFET

 /P1FBL4FBTPOSBUFT	OPSNBMMZIJHIFS+VOFUISPVHI"VHVTU


 6QUP
DPWFSBHFPOZPVSIPVTFIPMEHPPETBUOPBEEJUJPOBMDPTU

0OFDBMMUP/PSUI"NFSJDBO7BO-JOFTXJMMBTTJTUZPVJOZPVSSFMPDBUJPOCFGPSF
EVSJOHBOEBGUFSZPVSNPWF'PSNPSF

JOGPSNBUJPODBMM
BOENBLFTVSFUPJEFOUJGZZPVSTFMGBTB#VZJOH/FUXPSLNFNCFS

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 115 of 166


"VUP3FOUBM%JTDPVOUT

$#"NFNCFSTSFDFJWFTQFDJBMEJTDPVOUTUISPVHI/BUJPOBMBOE"MBNPCZTJNQMZDBMMJOHUIFUPMMGSFFOVNCFSTMJTUFE

CFMPXBOEQSPWJEJOHUIF$VTUPNFS4FSWJDF3FQSFTFOUBUJWFXJUIUIFDPSSFTQPOEJOHSBUFDPEF

.FNCFSTSFDFJWFEJTDPVOUTPOTFMFDUFEBVUPSFOUBMTUISPVHINPTUNBKPSDPNQBOJFT"MBNP
#VEHFU
%PMMBS
/BUJPOBM

BOE5ISJGUZBVUPSFOUBMBHFODJFT	$VSSFOUEJTDPVOUTBSFTVCKFDUUPDIBOHFXJUIPVUOPUJDF
5IFTFEJTDPVOUTBQQMZUP

SFOUBMTBUBMMQBSUJDJQBUJOHMPDBUJPOTJOUIF6OJUFE4UBUFT
$BOBEB
BOEXPSMEXJEF.FNCFSTBSFFODPVSBHFEUPDIFDL

XJUIUIFJSSFOUBMBHFOUGPSEFUBJMT

"MMNBKPSDSFEJUDBSETBSFBDDFQUFEGPSQBZNFOUPGSFOUBMT4IPVMEBDBSEIPMEFSFMFDUUPQBZDBTI
BDBTIEFQPTJUJTVTV

BMMZSFRVJSFEBUUIFUJNFPGSFOUBM

"DDFTTUPUIF"VUP3FOUBM%JTDPVOU1SPHSBN

"MBNP 


SFRVFTUSBUFDPEF	#:


#VEHFU 


5

%PMMBS 


$#

/BUJPOBM 


SFDBQ

5ISJGUZ 




2VBSUFSMZ$#"/FXTMFUUFS

$#"NFNCFSTSFDFJWFBTVCTDSJQUJPOUPUIJT$#"POMJOFNFNCFSTIJQQVCMJDBUJPO8FXJMMLFFQJOUPVDICZCSJOHJOH

ZPVJOGPSNBUJPOZPVDBOVTFUPNBOBHFZPVSGJOBODFT
JNQSPWFZPVSIFBMUIPSUBLFBWBDBUJPO$#"XJMMOPUJGZNFNCFST

PGBOZCFOFGJUDIBOHFTJOUIJTQVCMJDBUJPO:PVDBOEPXOMPBEUIJTQSPGFTTJPOBMMZQSFQBSFERVBSUFSMZQFSJPEJDBMGSPN

XXXDCBOFXTMFUUFSDPN&OUFSUIFQBTTXPSE$#"*GZPVEPOPUIBWFXFCBDDFTT
QMFBTFDBMMBOESFRVFTU

UIBUZPVSDPQJFTPGUIFOFXTMFUUFSTCFNBJMFEUPZPV



$#"/BUJPOBM)FBERVBSUFST

10
+FGGFSTPO$JUZ
.0

$#""ENJOJTUSBUJWF0GGJDF

10#PY%FOWFS
$0 

'BY

-FHBM$BSF"NFSJDB
*%$#"

%JTDPVOU'MPXFSTBOE(JGUT4&/%'5%	



BTLGPSQSPNPUJPOBMDPEFBOETBWF
XXXGUEDPNCVZOFU

#VEHFU5SVDL3FOUBM
$PEF

/PSUI"NFSJDBO7BO-JOFT
*%5IF#VZJOH/FUXPSL

  "VUP3FOUBM%JTDPVOUT

#VEHFU
50 5ISJGUZ


 %PMMBS
$# "MBNP
DPEF	#:


 /BUJPOBM
SFDBQ

2VFTUJPOTDPODFSOJOH"TTPDJBUJPO#FOFmUTTIPVMECFEJSFDUFEUP

$#""ENJOJTUSBUJWF0öDF
10#PY
%FOWFS
$0

'BY

CBA

Consumer Benefits

of America

DIPJDFPOMJOF

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 116 of 166
HCCL STMM 102 CA 1 

HCC LIFE INSURANCE COMPANY 

225 TownPark Drive, Suite 350 

Kennesaw, Georgia 30144 

866-400-7102 

CERTIFICATE OF INSURANCE 

PROVIDING SHORT TERM MAJOR MEDICAL INSURANCE 

Group Policy No. STM600-1 (“the policy”), has been issued to Consumer Benefits of America 

which we will refer to as “the Policyholder”. We will refer to HCC Life Insurance Company as 

“the Company”, “we”, “us”, “our”. 

The policy was delivered in Missouri and will be governed by the laws thereof. 

This Certificate of Insurance is evidence of the Insured’s insurance under the policy and of its 

benefits. Everything contained in this Certificate of Insurance is subject to the provisions, 

definitions, and exceptions in the policy. The policy is on file with the Policyholder and may be 

examined at any reasonable time. Only one of our executive officers can authorize a change of 

the policy. 

This Certificate replaces all Certificates and Certificate Riders, if any, previously issued to the 

Insured under the policy. 

Signed for HCC Life Insurance Company: 

President: 

Corporate Secretary: 

 

THIS CERTIFICATE IS EVIDENCE OF A CONTRACT 

BETWEEN THE POLICYHOLDER AND THE COMPANY 

READ IT CAREFULLY

For service or complaints about this policy, please address any inquiries to 

the address shown above or call 866-400-7102. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 117 of 166
HCCL STMM 102 CA 2 

TABLE OF CONTENTS 

PART I GENERAL DEFINITIONS ................................................................ Page 3 

PART II ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE ........................ Page 7 

PART III TERMINATION OF INSURANCE ..................................................... Page 8 

PART IV PREMIUMS ...........................................................................................Page 10 

PART V DESCRIPTION OF MEDICAL EXPENSES ...................................... Page 11 

PART VI EXCLUSIONS........................................................................................Page 18 

PART VII COORDINATION OF BENEFITS ..........................................................Page 22 

PART VIII CLAIM PROVISIONS .................................................................................. Page 25 

PART IX GENERAL PROVISIONS ......................................................................Page 27 

PART X SCHEDULE OF BENEFITS ................................................................ Page 28 

OPTIONAL BENEFIT RIDERS, IF ANY 

AMENDMENT RIDERS, IF ANY 

NOTE: NO CONTINUOUS COVERAGE. This Certificate of insurance provides coverage 

for a short term duration only. It is not renewable. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 118 of 166
HCCL STMM 102 CA 3 

PART I – GENERAL DEFINITIONS 

“Accident” means a sudden, unforeseeable event that causes injury to one or more Covered 

Persons. 

“Complications of Pregnancy” means: 

1. Conditions requiring Inpatient treatment (when pregnancy is not terminated); 

2. Whose diagnoses are distinct from pregnancy but are adversely affected or caused by 

pregnancy, such as hyperemesis gravidarum, preeclampsia, acute nephritis, nephrosis, 

cardiac decompensation, missed abortion and similar medical and surgical conditions of 

comparable severity, but shall not include false labor, occasional spotting, Doctor 

prescribed rest during the period of pregnancy, morning Sickness, and other similar 

conditions associated with the management of a difficult pregnancy not constituting a 

nosologically distinct complication of pregnancy; and 

3. Non-scheduled or emergency cesarean section, ectopic pregnancy that is terminated, 

and spontaneous termination of pregnancy that occurs during a period of gestation in 

which a viable birth is not possible. 

“Congenital Condition” means a disease or other anomaly existing at or before birth, whether 

acquired during development or by heredity. 

“Coverage Period” means the length of time which the Insured selected in the Insured’s 

application and approved by us, not to exceed a month period commencing on the 

Effective Date. The Insured’s Coverage Period is shown in the Schedule of Benefits. 

“Covered Person” means an Insured and his eligible dependents for whom coverage is in effect 

under the policy, as described in Part II – Eligibility and Effective Date of Insurance Provisions 

and the Schedule of Benefits. 

“Custodial or Convalescence Care” means any care that is provided to a Covered Person who 

is disabled and needs help to support the essential activities of daily living when the Covered 

Person is not under active and specific medical, surgical, or psychiatric treatment that will 

reduce the disability to the extent necessary for the person to perform the essentials of daily 

living on his own. 

“Deductible” means the amount of covered expenses that must be paid by a Covered Person 

before benefits are payable under the policy. This amount applies separately to each Covered 

Person and must be satisfied each Coverage Period. 

“Doctor” means any duly licensed practitioner who is recognized by the law of the state in which 

treatment is received as qualified to perform the service for which claim is made. 

“Eligible Dependent” means: 

1. The Insured’s lawful spouse; and 

2. The Insured’s unmarried children who are less than age 19. An unmarried child who is 

less than age 25 may also be included if the child is enrolled full-time in an accredited 

school or college. 

Dependent children may include stepchildren, foster children, legally adopted children, children 

of adopting parents pending finalization of adoption procedures, and children for whom 

coverage has been court-ordered. 

six (6)

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 119 of 166
HCCL STMM 102 CA 4 

Dependent children (other than those for whom coverage has been court-ordered) must be 

primarily dependent on the Insured for principal support and maintenance. 

Coverage for an unmarried dependent child who is: 

A. incapable of self sustaining employment by reason of a physically or mentally disabling 

injury, illness or condition; who became so incapacitated prior to the attainment of the 

limiting age set forth above, and 

B. chiefly dependent upon the Insured for support and maintenance, shall not terminate. 

Coverage shall continue as long as the certificate remains in force and the dependent is 

disabled. Proof of such incapacity and dependency must be furnished to Us within sixty 

(60) of receipt of notice by Us that such coverage will terminate. We will provide such 

notice at least 90 days prior to the date the Dependent child attains the limiting age. 

Continued proof may be requested, but not more frequently than once a year. 

“Durable Medical Equipment” means medical equipment that can withstand repeated use, is 

prescribed by a Physician, and is appropriate for use in the home. Covered DME is limited to a 

standard basic Hospital bed and/or a standard basic wheel chair. 

“Effective Date” means the date the Insured’s (and Eligible Dependents’ if applicable) coverage 

under the policy is effective. 

“Experimental Treatment” means in Our discretion a treatment, drug, device, procedure, supply 

or service and related services (or any portion thereof, including the form, administration or 

dosage) for a particular diagnosis or condition when any one of the following exists: 

1. The treatment, drug, device, procedure, supply or service is in any clinical trial or a 

Phase I, II or III trial. 

2. The treatment, drug, device, procedure, supply or service is not yet fully approved or 

recognized (for other than experimental, investigational, research or clinical trial 

purposes) by the National Cancer Institute (NCI), Food & Drug Administration (FDA), or 

other pertinent governmental agency or professional organization. 

3. The results are not proven through controlled clinical trials with results published in peerreviewed English language medical journals, to be of greater safety and efficacy than 

conventional treatment, in both the short and long term. 

4. The treatment, drug, device, procedure, supply or service is not generally accepted 

medical practice in the state where the Covered Person resides or as generally accepted 

throughout the United States as determined in Our discretion, by reference to any one or 

more of the following: peer-reviewed English-language medical literature, consultation 

with physicians, authoritative medical compendia, the American Medical Association, or 

other pertinent professional organization or governmental agency. 

5. The treatment, drug, device, procedure, supply or service is described as investigational, 

experimental, a study, or for research or the like in any consent, release or authorization 

which the Covered Person, or someone acting on his or her behalf, may be required to 

sign. 

The fact that a procedure, service, supply, treatment, drug, or device may be the only hope for 

survival will not change the fact that it is otherwise experimental in nature. 

“Extended Care Facility” means an institution, other than a Hospital, operated and licensed 

pursuant to law, that provides: 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 120 of 166
HCCL STMM 102 CA 5 

1. Permanent and full-time facilities for the continuous skilled nursing care of three (3) or 

more sick or injured persons on an Inpatient basis during the convalescent stage of their 

illnesses or injuries; 

2. Full-time supervision of a Doctor; 

3. Twenty-four (24) hour a day nursing service of one or more Nurses; and 

4. Is not, other than incidentally, a rest home or a home for custodial care or for the aged. 

Extended Care Facility does not include an institution that primarily engages in the care 

and treatment of drug addiction or alcoholism. 

“Home Health Care Agency” means an entity licensed by state or local law operated primarily to 

provide skilled nursing care and therapeutic services in an individual’s home and: 

1. Which maintains clinical records on each patient; 

2. Whose services are under the supervision of a Doctor or a licensed graduate registered 

nurse (RN); and 

3. Which maintains operational policies established by a professional group including at 

least one Doctor and one licensed graduate registered nurse (RN). 

“Home Health Care Plan” means a program for continued care and treatment of an individual 

established and approved in writing by the individual’s attending Doctor. As part of the plan, an 

attending Doctor must certify that proper treatment of the Injury or Sickness would require 

continued confinement in a Hospital in the absence of the services and supplies. 

“Hospital” means an institution operated by law for the care and treatment of injured or sick 

persons; has organized facilities for diagnosis and surgery or has a contract with another 

hospital for these services; and has 24-hour nursing service. Hospital excludes any institution 

that is primarily a rest home, nursing home, convalescent home, a home for the aged, an 

alcoholism or drug addiction treatment facility. 

“Immediate Family” means the parents, spouse, children, or siblings of a Covered Person, or 

any person residing with a Covered Person. 

“Injury” means accidental bodily Injury of a Covered Person: 

1. Caused by an Accident; and 

2. That results in covered loss directly and independently of all other causes. 

All Injuries sustained in one Accident, including all related conditions and recurring symptoms of 

the Injuries, will be considered one injury. 

“Inpatient” means a person who incurs medical expenses for at least one day’s room and board 

from a Hospital. 

“Insured” means a person who meets the eligibility requirements for an Insured as stated in the 

Master Application and the policy, and whose coverage under the policy has become effective 

and has not terminated. 

“Medically Necessary” means the care, service or supply is: 

1. Prescribed by a Doctor for the diagnosis or treatment of an Injury or Sickness; and 

2. Appropriate, according to conventional medical practice for the Injury or Sickness in the 

locality in which the care, service or supply, is given. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 121 of 166
HCCL STMM 102 CA 6 

“Mental and Nervous Disorder” means a “biologically-based” mental disorder, including 

Schizophrenia, Schizoaffective disorder, Major depressive disorder, Bipolar disorder, Paranoia 

and other psychotic disorders, Obsessive-compulsive disorder, Panic disorder, Delirium and 

dementia, Affective disorders, and any other "biologically-based" mental disorders appearing in 

the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric 

Association (the "DSM"). 

“Outpatient” means a person who incurs medical expenses at Doctor’s offices and freestanding 

clinics, and at Hospitals when not admitted as an Inpatient. 

“Regular and Customary Activities” means an Insured Person can carry on a substantial part of 

the standard and commonly practiced activities of a person in good health of the same sex and 

age. Activities performed while confined in a Hospital or other medical institution may not be 

used to meet this requirement. 

“Routine Physical Exam” means examination of the physical body by a Doctor for preventive or 

informative purposes only, and not for the diagnosis or treatment of any condition. 

“Sickness” means Sickness or disease of a Covered Person that: 

1. Is treated by a Doctor while the person is covered under the policy; and 

2. Results directly and independently of all other causes in loss covered by the policy. 

“Substance Abuse” means the overindulgence in and dependence on a psychoactive leading to 

effects that are detrimental to the individual's physical health or mental health, or the welfare of 

others. 

“Surgery or Surgical Procedure” means an invasive diagnostic procedure; or the treatment of 

Injury or Sickness by manual or instrumental operations performed by a Doctor while the patient 

is under general or local anesthesia. 

“Total Disability” (or “Totally Disabled”) means the Insured is disabled and prevented from 

performing the material and substantial duties of his or her occupation. For Dependents, 

“Totally Disabled” means the inability to perform a majority of the normal activities of a person of 

like age in good health. 

“Urgent Care Center” means a medical facility separate from a hospital emergency department 

where ambulatory patients can be treated on a walk-in basis without an appointment and 

receive immediate, non-routine urgent care for an Injury or Sickness presented on an episodic 

basis. 

“Usual and Customary” charges means the following: 

1. A usual fee is defined as the charge made for a given service by a Doctor to the majority 

of his or her patients; and 

2. A customary fee is one that is charged by the majority of Doctors within a community for 

the same services. All benefits are limited to Usual and Customary charges. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 122 of 166
HCCL STMM 102 CA 7 

PART II – ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE 

Coverage will be effective for an Insured and his Eligible Dependent(s) as of the approved 

Effective Date, provided: 

1. The Insured meets the eligibility requirements set forth in the Master Application and the 

Policy; 

2. The Insured's Application is approved by Us; 

3. The first premium payment is received on or before the date the Insured's Application is 

approved by Us; 

4. The Insured is not confined at home or in a Hospital or medical institution as of the 

Effective date; and 

5. The Insured is engaging in his Regular and Customary Activities as of the Effective date. 

If the Insured is not engaged in his Regular and Customary Activities or is confined in a Hospital 

or medical institution on the Effective Date, coverage will begin the first day he can engage in 

his Regular and Customary Activities and is not confined in a Hospital or medical institution. 

The Company will require satisfactory evidence of insurability for each Insured and Eligible 

Dependent. 

Newborn Child Coverage: A child of the Insured born while the policy is in force is covered for 

Injury and Sickness (including necessary care and treatment of congenital defects, birth 

abnormality and premature birth), as well as routine newborn care for the first 31 days. The 

child is covered from the moment of birth until the 31st day of age. A notice of birth together with 

additional premium must be submitted to us within 31 days of the birth in order to continue 

coverage for Injury and Sickness beyond the initial 31-day period. 

Adopted Children Coverage: A minor child who comes under the charge, care and control of 

the Insured while the policy is in force is covered for Injury and Sickness provided the Insured 

files a petition to adopt. The coverage of such child will be the same as provided for other 

members of the Insured’s family. Such child shall be covered from the date of placement in the 

Insured’s home if the Insured applies for coverage and pays any required premium within 31 

days after the date of placement. However, coverage shall begin at the moment of birth if the 

petition for adoption, application for coverage and payment of premium occurs within 31 days 

after the child’s birth. Such child’s coverage will not be subject to any pre-existing conditions 

limitation provided by the policy. Coverage for such minor child will continue unless the petition 

for adoption is dismissed or denied. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 123 of 166
HCCL STMM 102 CA 8 

PART III - TERMINATION OF INSURANCE 

Coverage of a Covered Person under the Policy shall automatically terminate on the earliest of 

the following dates: 

1. The date the Coverage Period expires; 

2. The first day of the month coinciding with or following the date other hospital, major 

medical, group health or other medical insurance coverage becomes effective for a 

Covered Person; 

3. The end of the last period for which the last required premium payment was made for 

the Insured’s or Covered Person’s insurance; 

4. The date a Covered Person receives the Coverage Period Maximum Benefit Amount; 

5. The date the Covered Person enters the armed forces of any country, state or 

international organization, other than for reserve duty of 30 days or less; 

6. The premium due date that coincides with or next follows the date on which the Insured 

is no longer eligible; 

7. For a Dependent spouse, the first day of the month following the date of divorce or legal 

separation from the Insured; or 

8. The date We specify that the Covered Person’s insurance is terminated because of: 

A. Failure to provide any signed release, consent, assignment or other documents 

requested by Us; 

B. Failure to fully cooperate with Us in the administration of the Policy; 

C. Material misrepresentation, fraud, or omission of information on any application 

form, or in requesting the receipt of benefits under the Policy; or 

D. Misuse of the Covered Person's identification card. 

At the death of an Insured, all rights and privileges as a Covered Person under the Policy will 

transfer to the surviving Dependent spouse. The Dependent spouse will then be considered an 

Insured instead of a Dependent. In the event the Dependent spouse remarries, coverage under 

the Policy for the Dependent Spouse and Dependent child(ren), if any, will end on the first day 

of the month following the date of that marriage. If no surviving Dependent spouse, or at the 

death of a surviving Dependent spouse, all rights and privileges as a Covered Person under the 

Policy will transfer to each Dependent child, if any, and he will be considered the Insured 

instead of a Dependent. 

If the Insured selected the Pay In Advance option in the Insured's Application and We received 

all required premium for the Coverage Period, premium will be reimbursed to the Insured for the 

period of time, if any, between the date coverage terminates in accordance with the above 

provisions and the end of that Coverage Period. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 124 of 166
HCCL STMM 102 CA 9 

Extension of Benefits 

If a covered Bodily Injury or Sickness commences while the Policy is in force as to a Covered 

Person, benefits otherwise payable under the Policy for the Injury or Sickness causing the Total 

Disability will also be paid for any Eligible Expenses incurred after the termination of insurance 

for a Covered Person if, from the date of such termination to the date such expenses are 

incurred, the Covered Person is Totally Disabled by reason of such Injury or Sickness. Such 

benefits shall be payable only during the continuance of such disability until the earlier of: 

1. The date the Total Disability ends; 

2. The date when treatment for the Total Disability is no longer required; 

 3. The date following a time period equal to the Covered Person's Coverage Period, with a 

minimum of thirty (30) days not to exceed a maximum of ninety (90) days; 

 4. The date the Covered Person becomes eligible for any other group insurance plan 

providing coverage for the same conditions causing the Total Disability; or 

 5. The date the Coverage Period Maximum Benefit amount has been reached

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 125 of 166
HCCL STMM 102 CA 10 

PART IV - PREMIUMS 

1. Unless the Pay In Advance option has been chosen, premium due dates for an Insured 

will be on the Effective Date and then the same date of each following calendar month. If a 

month has fewer days than the scheduled premium due date, premium will be due on the last 

day of the month. All insurance shall be charged from and to the premium due date. 

2. If any change or clerical error affects premiums, an equitable adjustment in premiums 

shall be made on the premium due date next following the date of the change or the discovery of 

the error. Any premium adjustment that involves collecting earned premiums, or returning 

unearned premium shall be limited to the six (6) months immediately preceding the date of 

determination that the adjustment in premium should be made. 

3. Premiums shall be payable in advance to Us at Our Home Office. 

4. If the Insured has not given written notice to Us that insurance is to be terminated prior to 

the premium due date, a grace period of thirty-one (31) days beginning from the premium due 

date will be allowed for any premium after the first premium. If the Insured fails to pay premium 

before the grace period expires all coverage shall lapse as of the premium due date. 

5. The Policy does not share in the surplus earnings of the Company and no refund or 

assessment shall be made to the Policyholder, Insured, or Dependent of any excess or deficit 

earnings of the Company. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 126 of 166
HCCL STMM 102 CA 11 

PART V – DESCRIPTION OF MEDICAL EXPENSES 

Subject to the Deductible, Coinsurance and other limits set forth in PART X – SCHEDULE OF 

BENEFITS, the Company will pay the following expenses incurred while this insurance is in 

effect: 

1. Charges made by a Hospital for: 

A. Daily room and board and nursing services not to exceed the average semiprivate room rate; 

B. Daily room and board and nursing services in Intensive Care Unit; 

C. Use of operating, treatment or recovery room; 

D. Services and supplies which are routinely provided by the Hospital to persons for 

use while Inpatients; 

E. Emergency treatment of an Injury, even if Hospital confinement is not required; 

and 

F. Emergency treatment of a Sickness; however, an additional $250 Deductible will 

apply to emergency room charges unless the Covered Person is directly 

admitted to the Hospital as an Inpatient for further treatment of that Sickness. 

2. For Surgery at an Outpatient surgical facility, including services and supplies. 

3. For charges made by a Doctor for professional services. 

4. For charges made by a Doctor for Surgery. Charges for an assistant surgeon are 

covered up to 20% of the Usual and Customary charge of the primary surgeon. 

(Standby availability will not be deemed to be a covered charge.). 

5. For dressings, sutures, casts or other supplies which are Medically Necessary and 

administered by or under the supervision of a Doctor, but excluding nebulizers, oxygen 

tanks, diabetic supplies, other supplies for use or application at home, and all devices or 

supplies for repeat use at home, except Durable Medical Equipment as herein defined. 

6. For diagnostic testing using radiology, ultrasonographic or laboratory 

services 

(psychometric, intelligence, behavioral and educational testing are not included). 

7. For artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial 

limbs, 

but not the replacement or repair thereof. 

8. For reconstructive surgery performed to correct or repair abnormal structures of the body 

caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or 

disease: 

A. to im pro ve f unct ion; or 

B. to create a normal appearance, to the extent possible. 

9. Reconstructive breast surgery and prosthetic devices incident to a Mastectomy. 

Coverage will also be extended to include surgery on a non-diseased breast to establish 

symmetry with the diseased breast. As used in this benefit: 

A. “Mastectomy” means the surgical removal of all or part of a breast as a result of 

breast cancer. 

B. “Reconstructive breast surgery” means surgery performed as a result of a 

mastectomy to reestablish symmetry between the two breasts and includes 

augmentation mammoplasty, reductive mammoplasty, and mastopexy. 

Coverage for prosthetic devices and reconstructive surgery means any initial or 

subsequent surgeries, prosthetic devices and any Medically Necessary follow up care. 

10. For radiation therapy or treatment and chemotherapy. 

11. For hemodialysis and the charges by the Hospital for processing and administration of 

blood or blood components but not the cost of the actual blood or blood components. 

12. For oxygen and other gasses and their administration by or under the 

supervision of a doctor. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 127 of 166
HCCL STMM 102 CA 12 

13. For anesthetics and their administration by a Doctor, subject to a maximum of 20% of 

the benefit payable for the primary surgeon. 

14. Extended Care Facility charges for room and board accommodations; if: 

A. The Insured is an Inpatient in that facility on the certification of the attending 

Doctor that the confinement is Medically Necessary;

B. The confinement commences immediately following a period of at least three (3) 

continuous days of Hospital confinement; and 

C. That confinement is for the same covered Injury or Sickness that was treated 

during the Covered Person's confinement in the Hospital. 

15. Treatment of a Covered Person by a Home Health Care Agency under a Home Health 

Care Plan. Up to four (4) consecutive hours in a twenty-four (24) hour period of Home 

Health Care services shall be considered as one Home Health Care visit. Eligible 

Expenses for Home Health Care are the Maximum Allowable Charges made for the 

following: 

A. Part-time skilled nursing care; 

B. Ph ys ic a l t h e r a p y; 

C. S p e e c h t h e r a p y ; 

D. Medical supplies, drugs and medicines prescribed by a Doctor; 

E. Laboratory services by or on behalf of the Hospital but only to the extent benefits 

for those services would have been paid under the Policy had the Insured Person 

remained Hospitalized; 

F. Occupational therapy; and 

G. R e s p i r a t o r y t h e r a p y . However, benefits will not be paid for charges 

made by a Home Health Care Agency for: 

A. Any charges excluded under the Exclusions of the certificate; 

B. Full-time nursing care at home; 

C. Meals delivered to the home; 

D. Homemaker services; 

E. Any services of an individual who ordinarily resides in the Insured’s home or is a 

member of the Insured's immediate family; or 

F. Any transportation services. 

Benefits for Home Health Care are in lieu of any similar benefits provided under any 

other provision of the certificate. 

16. Local Ambulance transport necessarily incurred in connection with Injury, and Local 

Ambulance transport necessarily incurred in connection with Sickness resulting in 

Inpatient hospitalization. 

17. Dental treatment and dental surgery necessary to restore or replace natural teeth lost or 

damaged as a result of an Injury covered under this certificate. 

18. Medically Necessary rental of Durable Medical Equipment (limited to a standard basic 

hospital bed and/or a standard basic wheelchair) up to the purchase prices, not including 

expenses for customization and only for the portion of the cost equivalent to the 

Coverage Period. 

19. Physical Therapy if prescribed by a Doctor who is not affiliated with the Physical Therapy 

practice, necessarily incurred to continue recovery from a covered Injury or Sickness. 

Pre-Certification Requirements 

1. All hospitalizations, other Inpatient care, and Surgeries or Surgical Procedures must be 

Pre-certified. 

2. To comply with the Pre-certification requirements, the Covered Person must: 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 128 of 166
HCCL STMM 102 CA 13

A. Contact the Company at 1-866-400-7102 as soon as possible before the 

expense is to be incurred; and 

B. Comply with the instructions of the Company and submit any information or 

documents they require; and 

C. Notify all Doctors, Hospitals and other providers that this insurance contains Precertification requirements and ask them to fully cooperate with the Company.

 3. If the Covered Person complies with the Pre-certification requirements, and the 

expenses are Pre-certified, the Company will pay Eligible Medical Expenses subject to 

all terms, conditions, provisions and exclusions described in this certificate. If the 

Covered Person does not comply with the Pre-certification requirements or if the 

expenses are not Pre-certified: 

A. Eligible Medical Expenses will be reduced by 50%; and 

B. The Deductible will be subtracted from the remaining amount; and 

C. The Coinsurance will be applied. 

 4. Emergency Pre-certification: In the event of an emergency Hospital admission, Precertification must be made within 48 hours after the admission, or as soon as is 

reasonably possible. 

 5. Pre-certification Does Not Guarantee Benefits – The fact that expenses are Pre-certified 

does not guarantee either payment of benefits or the amount of benefits. Eligibility for 

and payment of benefits are subject to all the terms, conditions, provisions and 

exclusions herein. 

 6. Concurrent Review – For Inpatient stays of any kind, the Company will Pre-certify a 

limited number of days of confinement. Additional days of Inpatient confinement may 

later be Pre-certified if a Covered Person receives prior approval. 

Pre-Certification Requirements for reconstructive surgery in connection with a mastectomy shall 

not be required in determining length of stay in a hospital following such surgery or procedure. 

Only a Doctor competent to evaluate the specific clinical issues involved in the care requested, 

can deny a request to authorize care for reconstructive surgery. 

State Mandated Benefits. 

The following benefits are mandated by applicable state law. All benefits will be subject to any 

inside benefit limitations set forth below, as well as the Coverage Period Maximum Benefit 

amounts shown on the Schedule of Benefits. 

 1. Dental Anesthesia – Coverage shall be provided for general anesthesia for dental care 

for a Dependent child if an underlying medical condition requires such anesthesia to be 

provided in a hospital or surgery center setting. Coverage shall only include payment 

for: 

A . a n e s t h e s i a ; a n d 

B . hospital or surgery center setting charges. 

The Dependent child must meet the following conditions: 

A. be under the age of seven (7); or 

B. be developmentally disabled, regardless of age; and 

C. it is determined that such child's health is compromised and general anesthesia 

is Medically Necessary. 

 2. Child Preventive Care - Coverage shall be provided for comprehensive child preventive 

care consistent with the following for children 16 years of age or younger: 

A. The recommendations for Preventive Pediatric Health Care, as adopted by the 

American Academy of Pediatrics of September 1987; 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 129 of 166
HCCL STMM 102 CA 14

B. The most current version of the Recommended Childhood Immunization 

Schedule/United States, jointly adopted by the: 

(a) American Academy of Pediatrics; 

(b) Advisory Committee on Immunization Practices; and 

(c) American Academy of Family Physicians; 

unless the State Department of Health Services determines, within 45 days of the 

published date of the schedule, that the schedule is not consistent with the 

purposes of this benefit provision. and 

C. Include benefits for: 

(a) periodic health evaluations; 

(b) immu nizat ions; an d 

(c) laboratory services in connection with periodic health evaluations. 

 3. Mammography Screening - Coverage shall be provided for the screening and

diagnosis of breast cancer based on the following: 

A. A baseline mammogram for a woman who is thirty-five (35) to forty (40) years of 

age; 

B. A mammogram for a woman who is forty (40) to forty-nine (49) years of age, 

every two years, or more frequently, based on the recommendation of the 

woman’s Doctor; 

C. A mammogram each year for a woman who is at least fifty years (50) of age; 

 4. Laryngectomy - Coverage shall be provided for prosthetic devices to restore speech 

after a laryngectomy. 

As used here: 

Laryngectomy means the Medically Necessary removal of the larynx. 

Prosthetic devices means initial and replacement prosthetic devices, including 

installation accessories prescribed by a Doctor. It does not include an electronic voice 

producing machine. 

 5. Prostate Screenings - Coverage shall be provided for the screening and diagnosis of 

prostate cancer. Coverage shall include, but not be limited to: 

A. prostate specific antigen testing; and 

B. digital rectal examinations. 

Coverage does not include: 

A. radical prostatectomy; 

B. external beam radiation therapy; 

C. radiation seed implants; or 

D. combined hormonal therapy. 

 6. Cervical Cancer Screenings - Coverage shall be provided for an annual cervical 

cancer screening test including a Pap test or any cervical cancer screening test 

approved by the FDA and recommended by a Doctor. 

 7. Cancer Screening Tests - Coverage shall be provided for generally medically accepted 

cancer screening tests. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 130 of 166
HCCL STMM 102 CA 15

8. Phenylketonuria (PKU) Treatment - Coverage shall be provided for the testing and 

treatment of phenylketonuria (PKU). Such coverage will include formulas and special 

food products that are: 

A. part of a diet prescribed by a Doctor; 

B. managed by a health care professional in consultation with a Doctor who 

specializes in the treatment of metabolic disease. 

Such diet must be Medically Necessary to avoid the development of a serious physical 

or mental disability; or to promote normal development or function as a consequence of 

PKU. Coverage is only required to the extent it exceeds the cost of a normal diet. 

As used here: 

"Formula" means an enteral product for use at home that is prescribed or ordered by a 

Doctor or other authorized health care provider as Medically Necessary for the treatment 

of PKU. 

"Special food products" means a food product that is both: 

A. prescribed by a Doctor for the treatment of PKU and consistent with the 

recommendations and best practices of qualified health professionals with 

expertise germane to, and experience in the treatment and care of, PKU. It does 

not include a food that is naturally low in protein, but may include a food product 

that is specially formulated to have less than one gram of protein per serving; 

and 

B. used in place of normal food products, such as grocery store foods , used by the 

general population. 

9. Osteoporosis - Coverage shall be provided for the diagnosis, treatment and appropriate 

management of osteoporosis. Coverage will include, but not be limited to, FDA 

approved technologies such as bone mass measurement, as deemed medically 

appropriate. 

10. Severe Mental Illness/Serious Emotional Disturbances of a Child - Coverage for 

Medically Necessary treatment shall be provided for: 

A. diagnosis and treatment of severe mental illness for a Covered Person of any 

age; and 

B. emotional disturbances of a child who: 

(a) has one or more mental disorders as identified in the most recent edition 

of the Diagnostic and Statistical Manual of Mental Disorders, other than a 

primary substance use disorder or developmental disorder, that result in 

behavior inappropriate to such child's age according to expected 

development norms; and 

(b) meets one or more of the following: 

(i) displays psychotic features, risk of suicide, or risk of violence due 

to a mental disorder; or 

(ii) meets special education eligibility requirements pursuant to 

California state law; or 

(iii) has substantial impairment, as a result of the mental disorder, in 

at least two of the following areas: self-care, school functioning, 

family relationships, or ability to function in the community and 

either of the following occur: the child is at risk of removal from 

his/her home or has already been removed from the home; or the 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 131 of 166
HCCL STMM 102 CA 16

mental disorder and impairments have been present for more than 

six months or are likely to continue for more than one year without 

treatment. 

Benefits shall include charges incurred for: 

1. Outpatient services; 

2. Inpatient hospital services, including inpatient prescription drugs and 

3. Partial hospital services. 

As used here: 

"Severe mental illness" shall include: 

1. Schizophrenia or schizoaffective disorder; or 

2. Bipolar disorder (manic-depressive illness); or 

3. Major depressive disorder; or 

4. Pa n ic d is o r d e r ; o r 

5. Obsessive-compulsive disorder; or 

6. Pervasive developmental disorder or autism; or 

7. Anorexia nervosa or bulimia nervosa. 

 11. Diabetes - Coverage shall be provided for Medically Necessary supplies, equipment and 

management and treatment of insulin using diabetes, non-insulin using diabetes and 

gestational diabetes. Coverage shall include: 

A. Blood glucose monitors, including glucose monitors for the visually impaired; 

B. Blood glucose test strips, ketone urine testing strips; 

C. Insulin pumps and related necessary supplies; 

D. Lancets and lancet puncture devices; 

E. pen delivery systems for the administration of insulin; 

F. Podiatric devices to prevent or treat diabetes related complications; 

G. I n s u l in s yr in g e s ; 

H. Visual aids (but not eyewear) to assist the visually impaired with proper dosing of 

insulin. 

Coverage shall also include outpatient self-management training, education and medical 

nutrition therapy services necessary to enable the Covered Person to properly use the 

equipment and supplies listed above. Such services must be provided by an 

appropriately licensed or registered health care professional as prescribed by a health 

care professional legally authorized to prescribe the services. 

 12. AIDS Vaccine – Coverage shall be provided for a vaccine for Acquired Immune 

Deficiency Syndrome (AIDS) that is approved by the FDA and recommended by the U.S. 

Public Health Service. 

 13. Cancer Clinical Trials - Coverage shall be provided for routine patient costs for a 

Covered Person diagnosed with cancer and accepted into a phase I, phase II, phase III, 

or phase IV clinical trial for cancer. The Covered Person’s Doctor must recommend 

participation in the clinical trial and determine that it will have a meaningful potential 

benefit. Treatment must be provided in a clinical trial that: 

A. involves a drug that is exempt under federal regulations from a new drug 

application; or 

B. is approved by one of the following: 

(a) one of the National Institutes of Health (NIH);

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 132 of 166
HCCL STMM 102 CA 17

(b) the FDA, in the form of an investigational new drug application; 

(c) the U.S. Department of Defense; or 

(d) the U.S. Veterans’ Administration. 

“Routine patient costs” means costs associated with the provision of health care 

services, including drugs, items, devices, and services that would otherwise be covered 

under the plan or contract if those drugs, items, devices, and services were not provided 

in connection with an approved clinical trial program, including the following: 

A. Health care services typically provided absent a clinical trial. 

B. Health care services required solely for the provision of the investigational drug, 

item, device, or service. 

C. Health care services required for the clinically appropriate monitoring of the 

investigational item or service. 

D. Health care services provided for the prevention of complications arising from the 

provision of the investigational drug, item, device, or service. 

E. Health care services needed for the reasonable and necessary care arising from 

the provision of the investigational drug, item, device, or service, including the 

diagnosis or treatment of the complications. 

It does not include: 

A. drugs or devices not approved by the FDA and that are associated with the clinical 

trial; 

B. services other than health care services, such as travel, housing, companion 

expenses and other nonclinical expenses; 

C. any item or service that is provided solely to satisfy data collection and analysis 

needs and that is not used in the clinical management of the patient. 

D. health care services which, except for the fact that they are not being provided in a 

clinical trial, are otherwise specifically excluded under this certificate; or 

E. health care services customarily provided by the research sponsors free of charge 

for any enrollee in the trial. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 133 of 166
HCCL STMM 102 CA 18

PART VI – EXCLUSIONS 

Charges for the following treatments and/or services and/or supplies and/or conditions are 

excluded from coverage: 

 1. Pre-existing Conditions – Charges resulting directly or indirectly from a condition for 

which a Covered Person received medical treatment, diagnosis, care or advice within 

the six (6) month period immediately preceding such person’s Effective Date are 

excluded for the first six (6) months of coverage hereunder. A Covered Person who 

was covered under creditable coverage within 63 days of enrolling under this certificate 

shall be given credit for the period of time under such coverage toward the satisfaction 

of this exclusion. This exclusion does not apply to a newborn or newly adopted child 

who is added to coverage under this certificate in accordance with PART II – 

ELIGIBILITY AND EFFECTIVE DATE OF INSURANCE. Creditable Coverage means 

any of the following: 

A. A g rou p h ea lth p lan; or 

B. Health insurance coverage (care under any hospital or medical service policy or 

certificate; hospital or medical service plan contract; or Health Maintenance 

Organization (HMO); or 

C. In d ividua l co verag e; or 

D. M e d i c a r e ; o r 

E. M e d i c a i d ; o r 

F. C H A M P U S ; o r 

G. A medical care program of the Indian Health Service or of a tribal organization; 

or 

H. A State health benefits risk pool; or 

I. A health plan offered under the Federal Employees Health Benefits Program 

(FEHBP); or 

J. A public health plan; or 

K. A health benefit plan under the Peace Corps Act.

Creditable coverage does not include accident only, credit, coverage for onsite medical 

clinics, disability income, Medicare supplement, long-term care insurance, dental, 

vision, coverage issued as a supplement to liability insurance, workers’ compensation 

insurance or similar law, automobile medical payment insurance, or insurance under 

which benefits are payable with or without regard to fault and that is statutorily required 

to be contained in any liability insurance policy or equivalent self-insurance. 

Any coverage under which an insured was covered prior to a break in coverage of 63 

consecutive days or more, not counting any waiting period or affiliation period required 

by any Creditable Coverage, will not be considered Creditable Coverage. 

 2. Outpatient Prescription Drugs, medications, vitamins, and mineral or food supplements 

including pre-natal vitamins, or any over-the-counter medicines, whether or not ordered 

by a Doctor. 

 3. Routine pre-natal care, Pregnancy, childbirth, and postnatal care. (This exclusion does 

not apply to “Complications of Pregnancy” as defined.) 

 4. Alcoholism. 

 5. Substance abuse. 

 6. Charges which are not incurred by a Covered Person during his/her Coverage Period. 

 7. Treatment, services or supplies, which are not administered by or under the supervision 

of a Doctor. 

 8. Treatment, services or supplies which are not Medically Necessary as defined. 

 9. Treatment, services or supplies provided at no cost to the Covered Person. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 134 of 166
HCCL STMM 102 CA 19

10. Charges which exceed Usual and Customary charge as defined. 

11. Telephone consultations or failure to keep a scheduled appointment. 

12. Consultations and/or treatment provided over the Internet. 

13. Surgeries, treatments, services or supplies which are deemed to be Experimental 

Treatment. 

14. All charges Incurred while confined primarily to receive Custodial or Convalescence 

Care. 

15. Weight modification or surgical treatment of obesity, including wiring of the teeth and all 

forms of intestinal bypass surgery. 

16. Modifications of the physical body in order to improve the psychological, mental or 

emotional well-being of the Covered Person, such as sex-change surgery. 

17. Surgeries, treatments, services or supplies for cosmetic or aesthetic reasons, except for 

reconstructive surgery which is expressly covered under this certificate. 

18. Any drug, treatment or procedure that either promotes or prevents conception including 

but not limited to: artificial insemination, treatment for infertility or impotency, 

sterilization or reversal of sterilization. 

19. Any drug, treatment or procedure that either promotes, enhances or corrects impotency 

or sexual dysfunction. 

20. Abortions, except in connection with covered Complications of Pregnancy or if the life of 

the expectant mother would be at risk. 

21. Dental treatment, except for dental treatment that is expressly covered under this 

certificate. 

22. Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual 

therapy, and any examination or fitting related to these devices, and all vision and 

hearing tests and examinations. 

23. Eye surgery, such as radial keratotomy, when the primary purpose is to correct 

nearsightedness, farsightedness or astigmatism. 

24. Treatment for cataracts. 

25. Treatment of the temporomandibular joint, except for medically necessary surgical 

procedures for covered conditions directly affecting the upper or lower jawbone or 

associated bone joints. 

26. Injuries resulting from participation in any form of skydiving, scuba diving, auto racing, 

bungee jumping, hang or ultra light gliding, parasailing, sail planing, flying in an aircraft 

(other than as a passenger on a commercial airline), rodeo contests or as a result of 

participating in any professional, semi-professional or other non-recreational sports 

including boating, motorcycling, skiing, riding all-terrain vehicles or dirt-bikes, 

snowmobiling or go-carting. 

27. Injuries or Sicknesses resulting from participation in interscholastic, intercollegiate or 

organized competitive sports. 

28. Injury resulting from being under the influence of or due wholly or partly to the effects of 

alcohol or drugs, other than drugs taken in accordance with treatment prescribed by a 

Doctor, but not for the treatment of Substance Abuse. 

29. Willfully self-inflicted Injury or Sickness. 

30. Immunizations and Routine Physical Exams, except as expressly covered under this 

certificate or under a Rider attached to this certificate. 

31. Services received for any condition caused by a Covered Person’s commission of or 

attempt to commit a felony or to which a contributing cause was the Covered Person 

being engaged in an illegal occupation. 

32. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or 

music therapy, holistic care of any nature, massage and kinestherapy. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 135 of 166
HCCL STMM 102 CA 20

33. Any services performed or supplies provided by a member of the Insured’s Immediate 

Family. 

34. Orthoptics and visual eye training. 

35. Services or supplies which are not included as Eligible Expenses as described herein. 

36. Care, treatment or supplies for the feet: orthopedic shoes, orthopedic prescription 

devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable 

or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or 

toenails. 

37. Care and treatment for hair loss including wigs, hair transplants or any drug that 

promises hair growth, whether or not prescribed by a Doctor. 

38. Treatment of sleep disorders. 

39. Hypnotherapy when used to treat conditions that are not recognized as Mental or 

Nervous Disorders by the American Psychiatric Association, and biofeedback, and nonmedical self-care or self-help programs. 

40. Any services or supplies in connection with cigarette smoking cessation. 

41. Exercise programs, whether or not prescribed or recommended by a Doctor. 

42. Treatment required as a result of complications or consequences of a treatment or 

condition not covered under this certificate. 

43. Charges for travel or accommodations, except as expressly provided for local 

ambulance. 

44. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or 

radioactive material(s). 

45. Organ or Tissue Transplants or related services. 

46. Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea, 

sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic 

conditions of skin, nevus. 

47. Services received or supplies purchased outside the United States, its territories or 

possessions, or Canada. 

48. Treatment for or related to any congenital condition, except as it relates to a newborn or 

adopted child added as a Covered Person to this certificate. 

49. Spinal manipulation or adjustment. 

50. Sclerotherapy for veins of the extremities. 

51. Expenses during the first 6 months after the Effective Date of coverage for a Covered 

Person for the following (subject to all other coverage provisions, including but not 

limited to the Pre-existing Condition exclusion): 

A. Total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis 

of carcinoma; 

B . T o n s i l l e c t o m y ; 

C . A d e n o i d e c t o m y ; 

D. Repair of deviated nasal septum or any type of surgery involving the sinus; 

E . M y r i n g o t o m y ; 

F . T y m p a n o t o m y ; 

G . H e r n i o r r h a p h y ; o r 

H. Ch o le c y s t e c t o m y. 

52. Chronic fatigue or pain disorders. 

53. Treatment or diagnosis of allergies, except for emergency treatment of allergic reactions. 

54. Treatment, medication or hormones to stimulate growth, or treatment of learning 

disorders, disabilities, developmental delays or deficiencies, including therapy. 

55. Kidney or end stage renal disease. 

56. Joint replacement or other treatment of joints, spine, bones or connective tissue 

including tendons, ligaments and cartilage, unless related to a covered Injury. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 136 of 166
HCCL STMM 102 CA 21

57. Expenses resulting from a declared or undeclared war, or from voluntary participation in 

a riot or insurrection. 

58. Expenses incurred by a Covered Person while on active duty in the armed forces. Upon 

written notice to Us of entry into such active duty, the unused premium will be returned 

to the Covered Person on a pro-rated basis. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 137 of 166
HCCL STMM 102 CA 22

PART VII – COORDINATION OF BENEFITS (COB) 

Some people have health care coverage through more than one medical insurance plan at the 

same time. COB allows these plans to work together so the total amount of all benefits will 

never be more than 100 percent of the allowable expenses during any coverage year. This 

helps to hold down the costs of health coverage. 

COB does not apply to life insurance or accidental death and dismemberment benefits. 

The term “plan” applies separately to each policy, contract agreement or other arrangements for 

benefits or services. The term “plan” also applies separately to that part of any policy, contract, 

agreement or other arrangements for benefits or services that coordinates its benefits with other 

plans and to that part that does not. 

When a plan provides benefits in the form of services rather than cash payment the reasonable 

cash value of each service rendered will be considered to be both: (1) an allowable expense; 

and (2) a benefit paid. 

Definitions. “Plan” – means any of the following which provides benefits or services for 

medical expenses: 

1. Any group insurance or group-type coverage, whether insured or uninsured. This 

includes prepayment, group practice, or individual practice coverage. 

2. Any federal, state or local governmental programs, or coverage required or provided by 

law. This does not include a state plan under Medicaid (Title XIX, Grants to States for 

Medical Assistance Programs, of the United States Social Security Act, as amended 

from time to time.) 

Each contract or other arrangement for coverage under the above paragraphs is a separate 

plan. Also, if an arrangement has two parts and COB rules apply to one of the two, each of the 

parts is construed to mean a separate Plan. 

The term "plan" does not include: 

1. Individual or family insurance or subscriber contracts; 

2 Individual or family coverage through Health Maintenance Organizations (HMOs); 

3. Individual or family coverage under other prepayment, group practice and individual 

practice plans; 

4. School accident-type coverages. (These contracts cover students for accidents only, 

including athletic injuries, either on a twenty-four hour basis or on a to-and-from school 

basis); 

5. Group or group-type hospital indemnity benefits of $100 per day or less; 

6. Medicare Supplement policies; 

7. A state plan under Medicaid. 

“Primary Plan (Primary)” – means the Plan which determines its benefits before those of the 

other Plan. When there are more than two (2) Plans, This Plan may be Primary as to one and 

Secondary as to another. 

“Secondary Plan (Secondary)” – means the Plan which determines its benefits after those of 

the other Plan. When there are more than 2 Plans, This Plan may be Secondary as to one and 

Primary as to another. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 138 of 166
HCCL STMM 102 CA 23

“This Plan” – means the benefits provided under this group policy. 

Effect on Benefits. Plans use COB to decide which plan should pay first for a covered 

expense. If the Primary Plan’s payment is less than the charge for the allowable expense, then 

the Secondary Plan will apply its benefit payment to the balance. 

The following rules will be used to establish the order of benefit determination: 

 1. A plan which does not have a COB provision will always be the Primary Plan. 

 2. The benefits of a plan which covers the person on whose expenses the claim is based 

as other than a dependent will be determined before the benefits of a plan which covers 

the person as a dependent. However, if the person is also a Medicare beneficiary, and if 

the rule established under the Social Security Act of 1965, as amended, makes 

Medicare secondary to the plan covering the person as a dependent of an active 

employee, the order of benefit determination is: 

A. First, benefits of a plan covering persons as an employee, member, or 

subscriber. 

B. Second, benefits of a plan of an active worker covering persons as a dependent. 

C. Third, Medicare benefits. 

 3. The benefits of a plan that covers a person for whom a claim is made as a dependent 

child will be determined under the following rules:

A. When the parents are married: the benefits of a plan which covers the child as a 

dependent of the parent whose birthday anniversary occurs earlier in the 

calendar year will be determined before the benefits of a plan which covers the 

child as a dependent of the parent whose birthday anniversary occurs later in the 

calendar year. 

B. If both parents have the same birthday the benefits of the plan that covered the 

parent longer are determined before those of the plan that covered the other 

parent for a shorter period of time. 

C. If the plans do not agree on the order of benefit rules because the other plan 

does not have the rule described in this section, but has a rule based upon the 

gender of the parent, the rule in the other plan will determine the order of 

benefits. 

D. When the parents are separated or divorced and the parent with custody has not 

remarried the benefits of a plan which covers the child as a dependent of the 

parent with custody of the child will be determined before the benefits of a plan 

which covers the child as a dependent of the parent without custody. 

E. When the parents are divorced and the parent who has custody of the child has 

remarried: (a) the benefits of a plan which covers the child as a dependent of the 

parent with custody will be determined before the benefits of a plan which covers 

the child as a dependent of the step-parent; and (b) the benefits of a plan that 

covers the child as a dependent of the step-parent will be determined before the 

benefits of a plan that covers the child as a dependent of the parent without 

custody. 

F. Despite (2) and (3) above, if there is a court decree which would otherwise 

establish financial responsibility for the medical, dental or other health care 

expenses with respect to the child, the benefit payment of a plan which covers 

the child as a dependent of the parent with such financial responsibility will be 

determined before the benefit payment of any other plan that covers the child as 

a dependent child. 

 4. The benefits of a plan that covers a person as a primary insured who is neither laid off 

nor retired, or as that primary insured’s dependent, are determined before those of a 

plan that covers that person as a laid off or retired primary insured or as that primary 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 139 of 166
HCCL STMM 102 CA 24

insured’s dependent. This rule will not apply if the other plan does not have this rule and 

if, as a result, the plans do not agree on the order of benefits. 

5. If a person whose coverage is provided under a right of continuation pursuant to federal 

or state law is covered under another plan, the following will be the order of benefit 

determination: 

A. First, the benefits of a plan covering the person as an employee, member, or 

subscriber (or as that person’s dependent); 

B. Second, the benefits under the continuation coverage. If the other plan does not 

have the rule described above and if, as a result, the plans do not agree on the 

order of benefits, this rule is ignored. 

6. When rules 2 through 5 do not establish an order of benefit determination the benefits of 

a plan which has covered the person on whose expenses the claim is based for the 

longer period of time will be determined before the benefits of a plan which has covered 

the person the shorter period of time. 

Facility of Payment. If another plan makes a benefit payment that should have been made by 

us we have the right to pay the other plan any amount we deem necessary to satisfy our 

obligation under these COB rules. 

Right of Recovery. If the amount of our benefit payment is more than the amount needed to 

satisfy our obligation under these COB rules, we have the right to recover the excess amount 

from: (A) any persons to or for whom, or with respect to whom, the payments were made; (B) 

any insurance companies; or (C) any other organizations. 

Right to Receive and Release Necessary Information. In order to carry out these COB rules: 

1. We have the right, without the consent of or notice to any person, to exchange 

information with any person, insurance company or organization, as we deem 

necessary; and 

2. Any person claiming benefits under this plan must give us any information necessary to 

carry out this provision. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 140 of 166
HCCL STMM 102 CA 25

PART VIII - CLAIM PROVISIONS 

Notice of Claim: Written notice of claim must be given within 31 days after a covered loss 

begins or as soon as is reasonably possible. The notice must be given to the Company named 

on the Schedule of Benefits. Notice should include information that identifies the claimant and 

the policy. 

Claim Forms: When the Company receives notice of claim, forms for filing proof of loss will be 

sent to the claimant. If claim forms are not supplied within 15 days, a claimant can give proof as 

follows: 

1 . I n w r i t i n g ; 

2 . Setting forth the nature and extent of the loss; and 

3 . Within the time stated in the Proof of Loss provision. 

Proof of Loss: Written proof of loss must be given to the Company within 90 days after the loss 

begins. We will not deny nor reduce any claim if it was not reasonably possible to give proof of 

loss in the time required. In any event, proof must be given to the Company within one year 

after it is due unless the Insured is legally incapable of doing so. 

Time of Payment of Claim: Benefits for loss covered by the policy will be paid as soon as we 

receive proper written proof of such loss, but no later than 30 working days after We receive 

Proof of Loss. 

Payment of Claims: All benefits will be paid to the Insured, if living, unless an Assignment of 

Benefits has been requested by the Insured. Any other benefits due and unpaid at the Insured’s 

death will be paid to the Insured’s estate. If a benefit is to be paid to the Insured’s estate, or to 

an Insured or beneficiary who is not competent to give a valid release, the Company may pay 

up to $1,000.00 of such benefit to one of the Insured’s relatives who is deemed by the Company 

to be justly entitled to it. Such payment, made in good faith, fully discharges the Company to 

the extent of the payment. 

Physical Examination: At our expense, we may have a person claiming benefits examined as 

often as reasonably necessary while the claim is pending. 

Legal Action: No legal action may be brought to recover on the policy before 60 days after 

written proof of loss has been furnished as required by the policy. No such action may be 

brought after three years from the time written proof of loss is required to be furnished. 

Third Party Liability: No benefits are payable for any Sickness, Injury, or other condition for which 

a third party may be liable or legally responsible by reason of negligence, an intentional act, or 

breach of any legal obligation on the part of such third party. Nevertheless, the Company will 

advance the benefits of this policy to the Insured subject to the following: 

1. The Insured agrees to advise Us, in writing, within 60 days of any Covered Person’s 

claim against the third party and to take such action, provide such information and 

assistance, and execute such paper as We may require to facilitate enforcement of the 

claim. The Insured and Covered Person also agree to take no action that may prejudice 

Our rights or interests under this policy. Failure to provide notice of a claim or to 

cooperate with Us, or actions that prejudice Our rights or interests, will be material 

breach of this policy and will result in the Insured being personally responsible for 

reimbursing Us. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 141 of 166
HCCL STMM 102 CA 26

2. We will automatically have a lien, to the extent of benefits advanced, upon any recovery 

that any Covered Person receives from the third party, the third party’s insurer, or the 

third party’s guarantor. Recovery may be by settlement, judgment or otherwise. The 

lien will be in the amount of benefits paid by Us under this policy for the treatment of the 

Sickness, disease, Injury or condition for which the third party is liable. 

Independent Medical Review: A Covered Person, or a representative acting on his or her 

behalf, has the right to request an independent medical review whenever healthcare services 

have been denied, modified or delayed by Us, if the decision was based in whole or in part on a 

finding that the proposed health care services are not medically necessary. A doctor, or other 

health care provider, may assist in seeking an independent medical review and may advocate 

on such Covered Person's behalf. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 142 of 166
HCCL STMM 102 CA 27

PART IX – GENERAL PROVISIONS 

Time Limit on Certain Defenses: The validity of coverage issued under the Policy with respect 

to an Insured or his Eligible Dependents may not be contested after three years from each 

certificate’s effective date, except for nonpayment of premiums. 

Misstatement of Age: If the age of any Covered Person is incorrectly stated, we will make a fair 

adjustment of the premiums, benefits or both. The adjustment will be based on the premiums 

and benefits that would have been payable had we known the correct information. 

Not in Lieu of Workers’ Compensation: The policy is not in lieu of and does not affect 

requirements for coverage under Workers’ Compensation laws. 

Pronouns: Whenever a personal pronoun in the masculine gender is used, it will be deemed to 

include the feminine also, unless the context clearly indicates to the contrary. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 143 of 166
HCCL STMM 102 CA 28

PART X – SCHEDULE OF BENEFITS 

INSURED INFORMATION: 

Name: 

Policy Effective Date: 

COVERAGE PERIOD: 

ELIGIBILE DEPENDENTS COVERED

COVERAGE AND BENEFIT AMOUNTS: 

Deductible per Covered Person per 

Coverage Period. Maximum of 3 

Deductibles per family per Coverage 

Period. 

An additional Deductible of $250 per visit 

will be applied to charges for use of 

emergency room in the event of Sickness 

unless the Covered Person is directly 

admitted as an Inpatient for further 

treatment. 

Coinsurance During a Coverage Period, the Company 

will pay of the next $5,000 of 

Eligible Expenses after the Deductible, 

then 100% of Eligible Expenses to the 

Overall Maximum Limit. 

Urgent Care Center For each visit, the Covered Person shall be 

responsible for a $50 co-payment, after 

which Coinsurance will apply. Not subject 

to Deductible 

Hospital Room and Board Average Semi-private room rate, including 

nursing services.

Local Ambulance Injury: Usual and Customary charges to a

Maximum of $250 per trip, when related to 

a covered Injury. 

Sickness: Usual and Customary charges to 

a maximum of $250 per trip, when covered 

Sickness results in hospitalization as 

Inpatient 

Intensive Care Unit Usual and Customary charges 

Physical Therapy $50 Maximum per visit per day 

Home Health Care Maximum 1 visit per day. Maximum of 40 

visits during a Coverage Period 

Extended Care Facility Not to exceed a daily rate of $150 nor a 

maximum of 60 days 

Steven Buckley

4/1/2016

6 Months

Danielle Buckley, , 

$7,500

50%

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 144 of 166
HCCL STMM 102 CA 29

All Other Eligible Medical Expenses Usual and Customary charges 

Penalty for Failure to Pre-certify 50% of Eligible Medical Expenses 

Overall Maximum Limit per Coverage 

Period $2,000,000

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 145 of 166
Medical Questions 

Please answer the questions below as they apply to the Applicant (Primary person listed 

above) applying for coverage. For each family member applying for coverage, complete and 

answer the questions on the Dependent Medical Questionnaire.

1. Will you have other health insurance in force on the policy effective date or be eligible for Medicaid?  Yes  No 

2. Have you: 

a. Been denied insurance due to any health reasons for a condition that is still present? 

b. Now pregnant, in process of adoption or undergoing infertility treatment? 

c. Over 300 pounds if male or over 250 pounds if female? 

 Yes  No 

3. Within the last 5 years have you been diagnosed, treated, or taken medication for any of the following: 

cancer or tumor, stroke, heart disease including heart attack, chest pain or had heart surgery, COPD 

(chronic obstructive pulmonary disease) or emphysema, Crohn's disease, liver disorder, degenerative 

disc disease or herniation/bulge, rheumatoid arthritis, kidney disorder, diabetes, degenerative joint 

disease of the knee, alcohol abuse or chemical dependency, or any neurological disorder? 

 Yes  No 

4. Within the last 5 years have you been diagnosed or treated by a physician or medical practitioner for 

Acquired Immune Deficiency Syndrome (AIDS)? 

 Yes  No 

5. If you are not a US Citizen, do you expect to legally reside in the US for the duration of the policy?  Yes  No 

 US citizen 

If you have answered “Yes” to questions 1 through 4 or “No” to question 5 above, coverage cannot be issued. 

Thank you for your interest. 

California law prohibits an HIV test from being required or used by health insurance companies as a condition of 

obtaining health insurance coverage. 

HCC Life STM 

Enrollment Form 

For use in CA 

Personal Details Please provide the following details for all individuals to be covered. 

Name (First and Last) Date of Birth Gender Contact Information 

Primary  Male 

 Female 

Address 

Spouse  Male 

 Female 

City State Zip 

Child 1  Male 

 Female 

Phone Number 

Child 2  Male 

 Female 

E-mail Address 

• Please complete this application entirely. Failure to provide 

complete information may delay processing. 

• You may elect the $5,000 and $7,500 deductible options by 

applying online or contacting us. 

Plan Options 

Please check the boxes corresponding to 

your elections for deductible and 

coinsurance.

Payment 

Option  Monthly – 6 month plan 

Deductible  $250  $500  $1,000  $2,500   Single Up Front (please specify term date)

Coinsurance  80% of $5,000  50% of $5,000 Specify Term Date ________________ 

Requested Effective Date _____/ ______ / _________ Number of days (max 180) _________

Please submit completed applications with 

payment to: 

HCC Life Insurance Company 

251 N. Illinois Street, Suite 600 

Indianapolis, IN 46204 

For product information or assistance with 

this enrollment form, please contact: 

 

HCCL STMM ENR CA (01/09) 

(Herein referred to as HCC Life)

X

Steven Buckley 2/24/

Danielle Buckley 4/25/ X

8/19/ X

9/30/ X

X

X $7500

X

4 1 2016

X

X

X

X

X

Healthy Halo Insurance Services, Inc.

800-788-2197

brent@healthyhalo.com

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 146 of 166
Payment Information 

Please provide complete payment information. 

Applications without payment cannot be processed. 

 Check/Money Order (Single Up-Front Payment 

Only)  MasterCard  VISA 

  Discover  American Express

Credit Card Number Exp Date 

Name on Card 

Pho

Billing Address (including city, state and zip) 

Check or Money Orders should be made payable, in 

US dollars, to HCC Life Insurance Company. If 

paying by credit card, I authorize HCC Life to debit 

my Discover, VISA, MasterCard or American 

Express account for the amount specified in the 

Rate Calculation section. If I have selected a 

monthly plan, I hereby request and authorize HCC 

Life to debit my Credit Card account for the proper 

installment amounts on the due dates of the 

installments. This authorization will remain in effect 

for the duration of the Coverage Period elected or 

until revoked by me in writing. Coverage purchased 

by credit card is subject to validation and 

acceptance by the credit card company. 

Cardholder Signature Date 

Authorization 

I hereby request coverage under the insurance issued to the Consumer Benefits of America Association and underwritten by 

HCC Life Insurance Company. I understand this insurance contains a Pre-existing Condition exclusion, a Pre-certification 

Penalty and other restrictions and exclusions. I agree that coverage will not become effective for me or any dependent whose 

medical status, prior to the effective date, has changed and therefore results in a “yes” answer to any of the medical questions 

on this application. If my medical status changes in this way, coverage will be declined for all individuals included on this 

application. I understand that if I have elected the Monthly Payment option, my credit card will be charged each month on the 

due date of the premium for 6 months, depending on the plan I have selected. I understand that I may terminate the scheduled 

payments by notifying HCC Life in writing at least one business day prior to the next scheduled payment date. I understand that

this coverage is not renewable or extendable. I understand that the information contained herein is a summary of the coverage 

offered in the Certificate of Insurance and that I may obtain a complete copy of the Certificate of Insurance upon request to HCC 

Life. I understand that HCC Life, as underwriter of the plan, is solely liable for the coverage and benefits provided under the

insurance. I understand and agree that the insurance agent/broker, if any, assisting with this application is a representative of 

the Applicant. If signed by a representative of the Applicant, the undersigned represents his/her capacity to so act. If signed as 

guardian or proxy of the Applicant, the undersigned represents his/her capacity to so act. By acceptance of coverage and/or 

submission of any claim for benefits, the Applicant ratifies the authority of the signer to so act and bind the Applicant. If I am not 

already a member of the Consumer Benefits of America Association, I hereby request to be enrolled as a member. I will receive 

a membership packet after my membership fees of $5 per month are received. Fraud Warning: Any person who knowingly and 

with intent to injure, defraud, or deceive any insurance company or other person submits an insurance application or statement 

of claim containing any materially false, incomplete or misleading information may be committing a crime and may be subject to 

civil or criminal penalties. 

Applicant Signature Date Spouse Signature Date 

Signed by HCC Life Appointed Agent: Plan Administrator Use Only: 

PBC 6CA.110.07.09 Code: 

Rate Calculation 

Use the rate table corresponding to your choice 

of plan option and coinsurance level to complete 

applicant rates below, then follow the calculation 

instructions. 

Monthly 

Payments 

Single Upfront Payment 

A Applicant’s Rate A A

B Spouse’s Rate B B

C Per child _________ x # ______ = C C

D A + B + C = D D

E Zip Code Factor E E

F 

D x E = Monthly / Daily 

Premium Total (round to the 

nearest penny) 

F F

G Monthly / Daily Association 

Fee G $5.00 G 

H F + G = Total Monthly / Daily 

Rate H H

I Number of to be 

Covered n/a I 

J H x I = n/a J

K Administrative Fee K $10.00 K $10.00 

L Total Due Monthly: H + K= 

Daily: J + K = L L

HCCL STMM ENR CA (01/09) 

X

128.16

xxxxxxxxxxxx7403 1/2019

96.92

Steven Buckley

21.72 2 43.44

268.52

2.4600 

$660.56

665.56

Months

$675.55

Signed Electronically 3/31/2016

Signed Electronically 3/31/2016 Signed Electronically 3/31/2016

236011180B

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 147 of 166
HCCL NPP revised 9/07 

- 1 - 

NOTICE OF PRIVACY PRACTICES 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE 

USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS 

INFORMATION. 

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL 

INFORMATION IS IMPORTANT TO US. 

Our Privacy Promise 

We will keep your medical information private. We will also give you this notice about 

our privacy practices, our legal duties and your rights concerning your medical 

information. We will follow the privacy practices that we describe in this notice while it is 

in effect. This notice took effect April 14, 2003, and will remain in effect until it is 

changed or replaced. 

We reserve the right to change our privacy practices and the terms of this notice at any 

time, as long as the law allows. We reserve the right to make these changes effective 

for all medical information that we keep, including medical information we created or 

received before we made the changes. Before we make a significant change in our 

privacy practices, we will change this notice accordingly and send the new notice to you 

prior to the effective date of the change. 

You may request a copy of this notice at any time or view a copy on our Web site at 

www.hcclife.com. 

Uses and Disclosures of Medical Information 

Treatment, Payment, Health Care Operations 

We may use and disclose your medical information for purposes of treatment, payment 

and health care operations. For example: 

Treatment: We may disclose your medical information to a physician or other health 

care professional so they can treat you. 

Payment: We may use and/or disclose your medical information for these and other 

related activities: 

• To pay claims from physicians, hospitals and other health care professionals 

for covered services you received. 

• To determine your eligibility for benefits. 

• To coordinate those benefits. 

• To determine medical necessity. 

• To obtain premiums. 

• To issue explanations of benefits to the named insured. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 148 of 166
HCCL NPP revised 9/07 

- 2 - 

We may also disclose your medical information to a health care professional or 

entity that is bound by the federal Privacy Rules so they can obtain payment or 

engage in payment activities. 

Health Care Operations: We may use and/or disclose your medical information in 

the normal course of our health care operations. This includes: 

• Determining our risk and premiums for your health plan. 

• Quality assessment and improvement activities. 

• Reviewing the qualifications of health care professionals; evaluating 

practitioner and provider performance; conducting training programs; and 

accreditation, certification, licensing and credentialing activities. 

• Medical review, legal services and auditing, including fraud and abuse 

detection and compliance programs. 

• Business planning and development. 

• Business management and general administrative activities, including 

management activities relating to privacy, customer service, internal 

grievances and creating de-identified information or a limited data set. 

We may disclose your medical information to another entity, which has a relationship 

with you and is also bound by the federal Privacy Rules, for its health care 

operations relating to quality assessment and improvement activities, reviewing the 

competence or qualifications of health care professionals, or detecting or preventing 

health care fraud and abuse. 

Your Authorization 

You may give us written authorization to use your medical information or to disclose it to 

anyone for any purpose. You may revoke your authorization in writing at any time. 

However, this will not affect any uses and disclosures we made while your authorization 

was in effect. Without your written authorization, we will not use or disclose your 

medical information for any reason except those described in this notice. 

Your Family and Friends

We may disclose your medical information to a family member, friend or other person to 

the extent necessary for them to assist with your health care, or with payment for your 

health care. We may also use or disclose your medical information to notify (or help 

notify, including identifying and locating) a family member, a personal representative or 

other person responsible for your care of your location, general condition or death. 

Before we disclose your medical information to that person, we will give you a chance to 

object to us doing so. If you are not available, or if you are incapacitated or in an 

emergency situation, we will disclose your medical information based on our 

professional judgment of what would be in your best interest. 

Your Employer or Organization Sponsoring Your Group Health Plan 

We may disclose summary information about you to your employer or plan sponsor for 

two reasons. One is to get premium bids for the health insurance coverage offered 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 149 of 166
HCCL NPP revised 9/07 

- 3 - 

through your group health plan. The second is to decide whether to modify, amend or 

terminate your group health plan. The summary information we may disclose 

summarizes claims history, claims expenses or types of claims members of your group 

health plan have filed. The summary information will not include demographic 

information about the people in the group health plan, but your employer or plan 

sponsor may be able to identify you or others from the summary information. 

Underwriting 

We may receive your medical information for underwriting, premium rating or other 

activities necessary to create, renew or replace a contract of health insurance or health 

benefits. We will not use or further disclose this medical information for any other 

purpose (except as required by law) unless the contract of health insurance or health 

benefits is placed with us, in which case we will use and disclose your medical 

information as described in this notice. 

Disaster Relief

We may use or disclose your medical information to a public or private entity authorized 

by law or by its charter to assist in disaster relief efforts. 

Public Benefit 

We may use or disclose your medical information as authorized by law for the following 

purposes that are in the public interest or benefit: 

• As required by law. 

• For public health activities, including disease and vital statistics reporting, child 

abuse reporting, FDA oversight, and to employers regarding work-related illness 

or injury. 

• To report adult abuse, neglect or domestic violence. 

• To health oversight agencies. 

• In response to court and administrative orders and other lawful processes. 

• To law enforcement officials in response to subpoenas and other lawful 

processes concerning crime victims, suspicious deaths, crimes on our premises, 

reporting crimes in emergencies and to identify or locate a suspect or other 

person. 

• To coroners, medical examiners and funeral directors. 

• To organ procurement organizations. 

• To avert a serious threat to health or safety. 

• In connection with certain research activities. 

• To the military and to federal officials for lawful intelligence, counterintelligence 

and national security activities. 

• To correctional institutions regarding inmates. 

• As authorized by state workers’ compensation laws.

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 150 of 166
HCCL NPP revised 9/07 

- 4 - 

Health-Related Services 

We may use your medical information to contact you about health-related benefits and 

services, or about treatment alternatives. We may disclose your medical information to 

a business associate to assist us in these activities. 

Marketing 

We may use or disclose your medical information to encourage you to purchase or use 

a product or service by face-to-face communication, or to provide you with promotional 

gifts of nominal value. 

Individual Rights 

Access 

You have the right to inspect or get copies of your medical information, with some 

exceptions. You may request that we provide copies in a format other than photocopies. 

We will use the format you request unless it is not practical to do so. To get your 

medical information, you must make a request in writing. If you request copies, we will 

charge you $0.50 for each page and for staff time to copy your medical information. We 

also will charge for postage if you want us to mail the copies to you. If you request 

another format, we will charge a cost-based fee for providing your medical information 

in that format. Contact us using the information listed at the end of this notice for a full 

explanation of our fees. 

Disclosure Accounting

You have the right to request, in writing, to receive a list of instances in which we (or our 

business associates) disclosed your medical information for purposes other than 

treatment, payment and health care operations, or as authorized by you, or for certain 

other activities allowed by law, on or after April 14, 2003. We will provide you with the 

date on which we made each disclosure, the name of the person or entity to which we 

disclosed your medical information, a description of the medical information we 

disclosed and the reason for the disclosure. If you request this accounting more than 

once in a 12-month period, we may charge you a reasonable, cost-based fee for each 

additional request. Contact us using the information listed at the end of this notice for a 

full explanation of our fees. 

Restriction 

You have the right to request, in writing, that we place additional restrictions on our use 

or disclosure of your medical information. We are not required to agree to these 

additional restrictions, but if we do, we will abide by our agreement (except in an 

emergency). Any agreement to additional restrictions must be in writing signed by a 

person authorized to make such an agreement for us. We will not be bound unless our 

agreement is in writing. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 151 of 166
HCCL NPP revised 9/07 

- 5 - 

Confidential Communications 

You have the right to request, in writing, that we communicate with you about your 

medical information by other means, or to other locations. You must state that you could 

be in danger if we do not communicate to you in confidence. We must accommodate 

your request if it is reasonable, if it specifies the other means or location, and if it 

permits us to continue to collect premiums and pay claims under your health plan. This 

includes sending explanations of benefits to the named insured of your health plan. We 

will not be bound to your confidential communications request unless our agreement is 

in writing. 

Even though you requested that we communicate with you about your health care in 

confidence, an explanation of benefits issued to the named insured for health care that 

the named insured (or others covered by the health plan) received might contain 

sufficient information, such as deductible and out-of-pocket amounts, to reveal that you 

obtained health care for which we paid. 

Amendment 

You have the right to request, in writing, that we amend your medical information. Your 

request must explain why we should amend the information. We may deny your request 

if we did not create the information you want amended and the person or entity that did 

create it is available, or we may deny your request for certain other reasons. If we deny 

your request, we will send you a written explanation. 

You may respond with a statement of disagreement that we will add to the information 

you wanted to amend. If we accept your request to amend the information, we will make 

reasonable efforts to inform others of the amendment, including people you name, and 

to include the changes in any future disclosures of that information. 

Electronic Notice 

If you are viewing this notice on our Web site or by electronic mail (e-mail), you may 

request this notice in written form by using the information listed at the end of this 

notice. 

Questions and Complaints 

If you want more information about our privacy practices, or if you have questions or 

concerns, please contact us using the information below. 

If you think that we may have violated your privacy rights, or you disagree with a 

decision we made about your privacy rights, you may tell us using the contact 

information listed below. You also may submit a written complaint to the U.S. 

Department of Health and Human Services. We will provide you with that address upon 

request. 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 152 of 166
HCCL NPP revised 9/07 

- 6 - 

We support your right to the privacy of your medical information. We will not retaliate in 

any way if you choose to file a complaint with us or with the U.S. Department of Health 

and Human Services. 

Contact Information 

HCC Life 

Bradley T. Long, Privacy Officer 

225 TownPark Drive, Suite 350 

Kennesaw, GA 30144 

(800) 447-0460 (telephone) 

(770) 973-9854 (fax) 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 153 of 166
EXHIBIT-16 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 154 of 166
ST ROSE HOSPITAL 

27200 CALAROGA AVE

HAYWARD, CA 94545

Patient Acct#: 

Certificate: 

Claim No.: 

DOB: January 14, 

Received Date: 01/19/2016

Service Date: December 13, 2015

February 01, 2016

 

Dear Provider, 

RE: AZAD, MOHOMMED 

We are in receipt of the above-referenced claim. However, before any further consideration can be 

given to this claim, we will need the following information:

all medical records, provider notes, and labs from 12/09/2010 through to present date

Please return this letter with the requested information to our office within 45 days of the date of 

this letter, and upon receipt, we will make a determination within 30 days. Failure to respond in a 

complete and timely manner may result in the denial of the patient's claim(s). 

CC: Member: MOHOMMED AZAD

Sincerely,

cdeputy

HCCL Claims Department

1-800-605-2282

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 155 of 166
MOHOMMED AZAD 

 

Patient Acct#: 

Certificate: 

Claim No.: 

DOB: January 14, 

Received Date: 01/19/2016

Service Date: December 13, 2015

February 01, 2016

 

Dear Provider, 

RE: AZAD, MOHOMMED 

We are in receipt of the above-referenced claim. However, before any further consideration can be 

given to this claim, we will need the following information:

all medical records, provider notes, and labs from 12/09/2010 through to present date

Please return this letter with the requested information to our office within 45 days of the date of 

this letter, and upon receipt, we will make a determination within 30 days. Failure to respond in a 

complete and timely manner may result in the denial of the patient's claim(s). 

CC: Member: MOHOMMED AZAD

Sincerely,

cdeputy

HCCL Claims Department

1-800-605-2282

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 156 of 166
EXHIBIT 17 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 157 of 166
MOHOMMED AZAD

 

Patient Acct. #: 

Certificate: 

Claim No.: 

DOB: January 14, 

Received Date: 1/29/2016

Service Date: December 27, 2015 

February 11, 2016

Dear Member, 

RE: AZAD, MOHOMMED 

The purpose of this letter is to confirm receipt of an additional claim, referenced above. We have

previously generated a letter to you requesting further information in order to determine claim

benefits for the following claim(s). 

Claim No.: 

Item Requested: medical records were previously requested from another provider

Date Requested: 2/1/2016

NO ACTION REQUIRED IF INFORMATION ALREADY SUBMITTED

If you have already submitted the information previously requested, please do not re-submit.

If you have yet to respond to our request, please visit https://zone.hccmis.com/clientzone/. 

This claim requires receipt of the information detailed above within 45 days of the date of this

request. Failure to respond in a complete and timely manner may result in the denial of your

claim(s). 

CC: Provider: ST ROSE HOSPITAL

Sincerely, 

HCCL Claims Department

1-800-605-2282

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 158 of 166
ST ROSE HOSPITAL

KAREN LIND 

27200 CALAROGA AVE

HAYWARD, CA 94545

Patient Acct. #: 

Certificate: 

Claim No.: 

DOB: January 14, 

Received Date: 1/29/2016

Service Date: December 27, 2015 

February 11, 2016

Dear Member,

RE: AZAD, MOHOMMED

The purpose of this letter is to confirm receipt of an additional claim, referenced above. We have

previously generated a letter to you requesting further information in order to determine claim

benefits for the following claim(s). 

Claim No.: 

Item Requested: medical records were previously requested from another provider

Date Requested: 2/1/2016

NO ACTION REQUIRED IF INFORMATION ALREADY SUBMITTED

If you have already submitted the information previously requested, please do not re-submit.

If you have yet to respond to our request, please visit https://zone.hccmis.com/clientzone/. 

This claim requires receipt of the information detailed above within 45 days of the date of this

request. Failure to respond in a complete and timely manner may result in the denial of your

claim(s). 

CC: Provider: ST ROSE HOSPITAL

Sincerely, 

HCCL Claims Department

1-800-605-2282

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 159 of 166
Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 160 of 166
Patient Acct#: 

Certificate: 

Claim No.: 

DOB: January 14, 

Received Date: 02/08/2016

Service Date: December 28, 2015

February 24, 2016

 

Dear Provider, 

RE: AZAD, MOHOMMED 

We are in receipt of the above-referenced claim. However, before any further consideration can be 

given to this claim, we will need the following information:

all medical records, provider notes, and labs from 12/09/2010 through to present date

Please return this letter with the requested information to our office within 45 days of the date of 

this letter, and upon receipt, we will make a determination within 30 days. Failure to respond in a 

complete and timely manner may result in the denial of the patient's claim(s). 

CC: Member: MOHOMMED AZAD

Sincerely,

cdeputy

HCCL Claims Department

1-800-605-2282

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 161 of 166
MOHOMMED AZAD 

 

Patient Acct#:

Certificate: 

Claim No.: 

DOB: January 14, 

Received Date: 02/08/2016

Service Date: December 28, 2015

February 24, 2016

 

Dear Provider, 

RE: AZAD, MOHOMMED 

We are in receipt of the above-referenced claim. However, before any further consideration can be 

given to this claim, we will need the following information:

all medical records, provider notes, and labs from 12/09/2010 through to present date

Please return this letter with the requested information to our office within 45 days of the date of 

this letter, and upon receipt, we will make a determination within 30 days. Failure to respond in a 

complete and timely manner may result in the denial of the patient's claim(s). 

CC: Member: MOHOMMED AZAD

Sincerely,

cdeputy

HCCL Claims Department

1-800-605-2282

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 162 of 166
EXHIBIT 19 

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 163 of 166
Page 1 of 1

Explanation of Benefits

RETAIN FOR TAX PURPOSES

THIS IS NOT A BILL

Phone:

Date: 08/29/16

Web Address:

866-400-7102

HCC Life Insurance Company

P.O. Box 2005

Farmington Hills, MI 48333-2005

Questions? http://service.hccmis.com

Mail to:

Customer Service

Not

Covered

Less

Discount

Less

Deductible

Payment

Amount

Amt. Subject

to Coinsurance

Paid

At

Dates of Service Reason

Code

Total Charge Less

Co-Pay

Service

Code

Claim #:

Patient's Share

of Coinsurance

Certificate #: Provider: ACCELERATED URGENT CARE

Patient: Danielle Buckley

06/17-06/17/2016 99204 $903.00 $903.00 86 $0.00 $0.00 $0.00 $0.00 50% $0.00 $0.00

$0.00

$0.00

Column Totals $903.00 $903.00 $0.00 $0.00 $0.00

Other Credits or Adjustments

Total Net Payment $0.00

$0.00

Total Patient's Responsibility: $903.00

$0.00

Service Code Description Reason Code Description

86 THIS FILE HAS BEEN CLOSED DUE TO A LACK OF REQUESTED

INFORMATION FROM THE PROVIDER(S). WE NEED A

COMPLETE COPY OF MEDICAL RECORDS TO REOPEN THIS

FILE.

Office or other outpatient visit for the evaluation and

management of a new patient, which requires these 3 key

components: A comprehensive history; A comprehensive

examination; Medical decision making of moderate complexity.

Counseling and/or coordinatio

99204

HCC Life Insurance Company

P.O. Box 2005

Farmington Hills MI 48333-2005

J954 [27,284] 1 of 3 20160830B02

1109 4961

Forwarding Service Requested

**************************3-DIGIT 933

AFAAAATTADDTTFTFATFFDTDDADDFATTTADDTADDADATAAAFATDTDDADDTFDADFDAD

27284 1 AT 0.399

STEVEN BUCKLEY

99

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 164 of 166
Page 1 of 1

Explanation of Benefits

RETAIN FOR TAX PURPOSES

THIS IS NOT A BILL

Phone:

Date: 08/30/16

Web Address:

866-400-7102

HCC Life Insurance Company

P.O. Box 2005

Farmington Hills, MI 48333-2005

Questions? http://service.hccmis.com

Mail to:

Customer Service

Not

Covered

Less

Discount

Less

Deductible

Payment

Amount

Amt. Subject

to Coinsurance

Paid

At

Dates of Service Reason

Code

Total Charge Less

Co-Pay

Service

Code

Claim #:

Patient's Share

of Coinsurance

Certificate #: Provider: ACCELERATED URGENT CARE

Patient: Danielle Buckley

06/18-06/18/2016 99214 $1,119.00 $1,119.00 86 $0.00 $0.00 $0.00 $0.00 50% $0.00 $0.00

$0.00

$0.00

Column Totals $1,119.00 $1,119.00 $0.00 $0.00 $0.00

Other Credits or Adjustments

Total Net Payment $0.00

$0.00

Total Patient's Responsibility: $1,119.00

$0.00

Service Code Description Reason Code Description

86 THIS FILE HAS BEEN CLOSED DUE TO A LACK OF REQUESTED

INFORMATION FROM THE PROVIDER(S). WE NEED A

COMPLETE COPY OF MEDICAL RECORDS TO REOPEN THIS

FILE.

Office or other outpatient visit for the evaluation and

management of an established patient, which requires at least 2

of these 3 key components: A detailed history; A detailed

examination; Medical decision making of moderate complexity.

Counseling and/o

99214

HCC Life Insurance Company

P.O. Box 2005

Farmington Hills MI 48333-2005

JA0E [10,565] 1 of 1 20160831B02

1109 4961

Forwarding Service Requested

**************************3-DIGIT 933

DDFDATTDDFTTATAAFTTAADTFDFAAFTADFADDDADAFFDTTFAADTFFAAAATTAFAAFDD

10565 1 AT 0.399

STEVEN BUCKLEY

41

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 165 of 166
Page 1 of 1

Explanation of Benefits

RETAIN FOR TAX PURPOSES

THIS IS NOT A BILL

Phone:

Date: 08/29/16

Web Address:

866-400-7102

HCC Life Insurance Company

P.O. Box 2005

Farmington Hills, MI 48333-2005

Questions? http://service.hccmis.com

Mail to:

Customer Service

Not

Covered

Less

Discount

Less

Deductible

Payment

Amount

Amt. Subject

to Coinsurance

Paid

At

Dates of Service Reason

Code

Total Charge Less

Co-Pay

Service

Code

Claim #:

Patient's Share

of Coinsurance

Certificate #: Provider: ACCELERATED URGENT CARE

Patient: Danielle Buckley

06/19-06/19/2016 99214 $777.00 $777.00 86 $0.00 $0.00 $0.00 $0.00 50% $0.00 $0.00

$0.00

$0.00

Column Totals $777.00 $777.00 $0.00 $0.00 $0.00

Other Credits or Adjustments

Total Net Payment $0.00

$0.00

Total Patient's Responsibility: $777.00

$0.00

Service Code Description Reason Code Description

86 THIS FILE HAS BEEN CLOSED DUE TO A LACK OF REQUESTED

INFORMATION FROM THE PROVIDER(S). WE NEED A

COMPLETE COPY OF MEDICAL RECORDS TO REOPEN THIS

FILE.

Office or other outpatient visit for the evaluation and

management of an established patient, which requires at least 2

of these 3 key components: A detailed history; A detailed

examination; Medical decision making of moderate complexity.

Counseling and/o

99214

HCC Life Insurance Company

P.O. Box 2005

Farmington Hills MI 48333-2005

J954 [27,284] 2 of 3 20160830B02

1109 4961

Forwarding Service Requested

STEVEN BUCKLEY

99

Case 4:17-cv-00618-PJH Document 52 Filed 04/13/17 Page 166 of 166