EXHIBIT C

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 1 of 76 PageID #: 27
Notice of Service of Process

null / ALL

Transmittal Number: 26829600

Date Processed: 04/28/2023

Primary Contact: SOP Team nwsop@nationwide.com

Nationwide Mutual Insurance Company

Three Nationwide Plaza

Columbus, OH 43215-2410

Electronic copy provided to: Ashley Roberts

Entity: Jefferson National Life Insurance Company

Entity ID Number 3859322

Entity Served: Jefferson National Life Insurance Company

Title of Action: Debra Veale vs. Jefferson National Life Insurance Coinpany

Matter Name/ID: Debra Veale vs. Jefferson National Life Insurance Coinpany (13991969)

Document(s) Type: Citation/Petition

Nature of Action: Class Action

Court/Agency: Grayson County District Court, TX

Case/Reference No: CV-23-0514

Jurisdiction Served: Texas

Date Served on CSC: 04/27/2023

Answer or Appearance Due: 10:00 am Monday next following the expiration of 20 days after service

Originally Served On: CSC

How Served: Personal Service

Sender Information: Wright Commercial Litigation

Not Shown

Information contained on this transmittal form is for record keeping, notification and forwarding the attached document(s). It does not

constitute a legal opinion. The recipient is responsible for interpreting the documents and taking appropriate action.

To avoid potential delay, please do not send your response to CSC

251 Little Falls Drive, Wilmington, Delaware 19808-1674 (888) 690-2882 | sop@cscglobal.com

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 2 of 76 PageID #: 28
i<__31 

%-A 1rl1~3 

KELLY ASHMORE PARTY(S) ATTORNEY 

Grayson County District Clerk Jason E. Wright 

Justice Center 8751 Collin McKinney Pkwy Suite 1102 #1088 

200 S. Crockett McKinney TX 75070 

Sherman, TX 7090 

CITATION 

The State of Texas 

NOTICE TO DEFENDANT: You have been sued. You inay employ an attotney. If you or your attorney do 

not file a written answer with the clerk whojssued.this citation by,10:00 a.m. on the Monday next 

following the expiration of twenty day/

s;:afterflyou were-served lhis°citation.-and petition, a default judgment 

may be taken against you. In addition to'filing'a wi•itten answer with the.:clerlc, you may be required to 

make initial disclosures to the other parties of tlus`su.it. These;disclosures geneially inust be made no later 

than 30 days after you tile''your answ

,

er witli the clerk.,.Eind,out~more at TexasL"awHelp. org. 

;.:-r._•, ti , ;,~.• ~' ,.-- 

„ ... . . . 

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Jefferson National,Life%Insurance Coinn.aiiy'..-..-~

Registered Agent = Corporation,Ser.vice Cnmpany

211 E. 7th Street, Suite 620 ..5 `.. 

Austin TX 78701 ~ ,.. 

—. 

Greetings:

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. . . .. . 

, : , . , .d..-4 ~ i.. . ... ^ . ,.„ ........ ..... ...... ~ . 

. , t^ " - -+~ .. ~ 

' 

• 

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You are hereliy conunanded, to appear '-:b•,y. filing a'<i-ritten answer to the ''I'I.AINTII'F'S 'ORIGINAL 

PETITION at or before teti::~'clock a.m: on the vlonday after the' expiratioti:;of twenty days after the date 

of scrvice of,.ttiis citatioii bef~re ~.the Honorable 59th ~Di'stricE Court of Gcayson'Cotmty, ;FeXas at the 

., : . . ,.. , 

Justice Centeir ofsaid County''ni;;Slierman, Tezas.,,Said Pdaintiffls Petitioritwas:"filed'in_.s"aidd'c`ourt on the 

24th day of April,'k023 thi~case; 'iiumbered C~'-23'-0514 on`the docket of said'court~l and styled:,~ 

'a

 ... 

,,....` ~ 

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, 

Debra Veale, individually and Qci:liclialf~q;f a~;~ others similarlyR si `• ated:y; :Tefferson Nation ~~it Insurance 

: p Company ~ .. 

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. 1 • ~ ! ' ~ )' ": " ' The nature of the Plairitiff's deman1. d,is fully;=shown' .by; a-true and. correct;copy of'alie PLATNTTFF'S 

ORIGINAL PETITION"accompanying this°citation aiid make a part liereo.f. = ', 

f

~ 

The officer executing this writ 'sliatl prompily serve the 'same_ according,to'~i'equirements of law, and the 

mandates thereof, and make due-retum`as..the law directs;

....„ •._ r ..... 

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Issued and given under hand and seal of said eourt•at Sherman; Texas 24th day of April, 2023. 

Kelly Ashmore 

District Clerk 

Grayson County, Texas 

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De P u n' •~ ~ ~'~~ ~ 

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Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 3 of 76 PageID #: 29
CV-23-0514 

SHERIFF'S RETURN 

Came to hand on day of at 

O'clock And executed in 

County, Texas by delivering to each of the within-named defendant(s), in Person, a true copy of this 

citation, having first endorsed thereon the date of delivery, Togetlier with the accompanying true and 

correct copy of the Plaintiff s Petition at The following tinies and places, to-wit: 

NAME I Date Yr-Da -Yr I Time I Place Course Dist from Court House 

Type of Service: Personal Posting Publication Otlier 

Type of Paper: 

And not executed as to the defendant, the 

Diligence used in finding said defendant being and 

The cause of failure to execute this process is and 

The information received as to the whereabouts of the said defendant 

Fees — Serving 

. County, Texas 

Sheriff/Constable/Police Chief 

Deputy 

UNSERVED RETURN 

Came to hand on at am/pin and was returned un-served to the 

issuing court after the following service attempts: 

Date/Time Location Notes 

Fees — Serving 

County, Texas 

S heriff/Constable/Pol ice Chief 

Deputy 

VERIFICATION OF RETURN (IF NOT SERVED BY PEACE OFFICER) 

State of Texas 

County of_ 

SUBSCRIBED AND SWORN TO BEFORE ME, the undersigned Notary Public, 

by , this day of 20 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 4 of 76 PageID #: 30
CV-23-0514 

CAUSE NO. 

DEBRA VEALE, individually and on 

behalf of all others similarly situated, 

Plaintif,f 

V. 

JEFFERSON NATIONAL LIFE 

INSURANCE COMPANY, 

Defendant. 

§ 

§ IN THE DISTRICT COURT OF 

§ 

§ 

§ § GRAYSON COUNTY, TEXAS 

§Grayson County - 59th District Court 

§ JUDICIAL DISTRICT 

§ 

FILED 

4/24/2023 12:43 PM 

Kelly Ashmore 

District Clerk 

Grayson County 

PLAINTIFF'S ORIGINAL PETITION 

Plaintiff Debra Veale, individually and on behalf of all others similarly 

situated, files this Original Petition, stating as follows: 

DISCOVERY CONTROL PLAN 

1. Counsel for Plaintiff intends to conduct discovery under Level 3 of 

Texas Rule of Civil Procedure ("TRCP") 190.4. 

STATEMENT OF CLAIM FOR RELIEF 

2. Pursuant to TRCP 47, and while reserving all rights to recover a 

greater amount as shown by the evidence, this suit initially seeks individual 

monetary relief over $250,000 but not more than $1 million. Absent discovery, the 

potential amount in controversy on a class basis is not known to Plaintiff. 

PARTIES 

3. Plaintiff Debra Veale is an individual residing in Sherman, Texas. 

4. Defendant Jefferson National Life Insurance Company ("JNLIC") is a 

Texas-chartered insurance company that designates Dallas as its domicile city with 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 5 of 76 PageID #: 31
the Texas Department of Insurance, and Corporation Service Company at 211 E. 

7th St, Ste 620, Austin, Texas 78701, as its registered agent for service of process. 

VENUE AND JURISDICTION 

5. Venue is proper because this is a suit against a life, accident, or healthinsurance company and Grayson County is where the policyholder resided when the 

cause of action accrued. See TEX. CIV. PRAC. & REM. CoDE § 15.032. 

6. The damages sought are within the jurisdictional limits of this Court. 

7. This Court has personal jurisdiction over JNLIC because it is 

chartered in Texas and regularly conducts and/or solicits business in, engages in 

other courses of conduct in, and/or derives revenue from persons in Texas. JNLIC 

has engaged, and continues to engage, in substantial and continuous business 

practices in and subject to the laws of the State of Texas. 

FACTS 

A. THE CANCER POLICIES AT ISSUE 

8. Since at least 1988, JNLIC's predecessor, Great American Reserve 

Insurance Company, sold guaranteed renewable cancer policies nationwide—from 

Dallas, Texas—that were issued as Form 22-9001 (09-88) (the "Policv").1

9. The Policy was prominently marketed as "THE CANCER FIGHTER," 

with accompanying statements creating a reasonable expectation that significant 

1 The class action is intended to encompass that policy issued as Form 22-9001 (09- 

88) and all other cancer treatment policies owned or administered by JNLIC that do 

not explicitly limit a payment of benefits to amounts owned after other insurance or 

payors have compensated a provider or adjusted a bill and, thus, the term "Policy" 

as used throughout shall also include all such other similar policies. 

N 

PLAINTIFF'S ORIGINAL PETITION Page 2 

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cash benefits would be paid if a covered person ever got cancer, as seen in the 

following type of brochure that was used at the time: 

10. The Policy and others like it were advertised as broadly covering all 

"treatment" and "expenses" for cancer. 

PLAINTIFF'S ORIGINAL PETITION Page 3 

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11. Indeed, the cover page of the Policy itself states: "We promise to pay 

the benefits described in this policy if any Insured Person ... incurs expenses, 

requires treatment, or otherwise suffers a covered loss as a result of cancer ...." 

12. In 1990, the Great American Reserve Insurance Company was 

acquired by an affiliate of Conseco, Inc. (part of the CNO Financial Group). The 

named insurer on the Policies then became Conseco Variable Life Insurance 

Company,2 which in 2003 changed its name to JNLIC. 

13. Nationwide Insurance or one of its affiliates then acquired the family 

of entities that includes JNLIC in or around 2016. 

B. THERE ARE FIVE CATEGORIES OF BENEFITS IN THE POLICY 

14. The benefits provided by the Policy and others like it administered by 

JNLIC can be grouped into five general areas: diagnosis, hospital confinement, 

treatment, transportation, and other care. 

(i) Diagnosis Benefits 

15. The Policy first is supposed to pay cash in three different ways based 

on a diagnosis of cancer,3 which can be summarized as follows: 

a. "Initial Diaanosis Benefit" — a$1,500 lump sum payable 

after the named insured person is diagnosed with cancer 

(or half that, $750, for an insured's dependent). 

b. "Cumulative First Occurrence Benefit" — an additional 

lump sum calculated at $30 per month (or half that, $15 

2 That entity was originally known as "Union Life Insurance Company." 

3 The only type of cancer not covered by the Policy is "skiri cancer." References to 

"cancer" in this pleading therefore do not include skin cancer. 

PLAINTIFF'S ORIGINAL PETITION Page 4 

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per month, for a dependent) for each full month that 

coverage was in force "after the waiting period"4 until the 

date of diagnosis or age 65, whichever is sooner. 

C. "Positive Diamostic Test Benefit" — the cost of lab tests, 

including x-rays, that show a positive diagnosis of cancer 

at any time, capped however at a$300 lifetime maximum. 

16. The Initial Diagnosis and Cumulative First Occurrence benefits are 

paid once with respect to a particular cancer in each insured person. 

(ii) Hospital Confinement Benefits 

17. Next, if an insured person (policyholder or covered dependent) is 

admitted to a hospital as a result of cancer, then the holder of the policy is entitled 

to be paid benefits summarized as follows: 

a. "Hospital Confinement Benefit" — a daily rate for 

overnight stays as set forth in a schedule (e.g., $200 per 

day for the first 70 days; $400 per day thereafter). 

b. "Prescription Drugs and Medicines Benefit" — the charges 

for prescription drugs and medicines administered during 

a hospital confinement, capped at $50 per day. 

C. "Attending Physician Benefit" — the cost for visits by a 

doctor other than a surgeon, capped at $30 per day. 

d. "Nursing Services Benefit" — the cost of private nursing 

care (meaning nurses not employed by the facility) during 

hospital confinement, capped at $180 per day. 

(iii) Treatment Benefits 

18. The Policy separately pays cash for cancer treatment, regardless of 

whether it occurs in or out of a hospital, as follows: 

4 The "waiting period" was eliminated in this respect by an amendatory 

endorsement—Form 22-7120 (01/90)—that was issued in 1990. 

PLAINTIFF'S ORIGINAL PETITION Page 5 

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a. "Surgical Benefit" — the fees charged for an operation 

performed for treatment of cancer, subject to a maximum 

per type of surgery as listed in a separate surgical 

schedule (e.g., $1,300 for a pancreatectomy, also known as 

a surgery to remove all or part of the pancreas) and then 

further multiplied by a"surgical factor" (e.g., 2.0) that is 

found in the main Policy schedule. 

b. "Anesthesia Benefit" — the costs of an anesthesiologist for 

a covered surgery, but limited to a maximum of 25% of 

the applicable Surgical Benefit to which it relates. 

C. "Blood, Plasma, and Platelets Benefit" — the costs of blood, 

plasma, and platelets at any time, with no maximum. 

d. "Prosthesis Benefit" — the cost of prosthetic devices 

required as a result of surgery, capped at a$1,000 

lifetime maximum. 

e. "Radiation. Chemotherabv. and Immunotherapv Benefit" 

— the "actual cost incurred" if receiving for the treatment 

of cancer any of the following types of therapies, stated in 

the Policy verbatim as: 

■ teleradiotherapy using either natural or artificially 

propagated radiation; 

■ interstitial or intracavity application of radium or 

radioisotopes in sealed or non-sealed sources; or 

■ cancericidal (cytotoxic) chemical substances to 

include the administration thereof. 

(iv) Transportation Benefits 

19. In addition, the Policy pays cash for certain transportation and lodging 

expenses incurred due to cancer that can be summarized as follows: 

a. "Ambulance Benefit" — the cost of air or ground 

ambulance transportation to a hospital for treatment of 

cancer, subject to maximums per period of confinement. 

b. "Transportation Benefit" — the costs of transportation by 

either private vehicle or a common carrier to and from a 

PLAINTIFF'S ORIGINAL PETITION Page 6 

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facility (not just a hospital) for treatment of cancer, if it is 

more than 50 miles froin the person's residence but also 

capped for private transportation at the lesser of either 

$0.40 per mile or $350 per round trip. 

C. "Family Member Lodaing Benefit" — the cost of a single 

room of lodging for a family member to stay near where 

the patient is confined to a hospital, provided the location 

is more than 50 miles from the person's home and subject 

further to maximums per day and period of confinement. 

(v) Other Care Benefits 

20. Finally, the Policy pays benefits for "extended facility" or "hospice" care 

related to cancer, each subject to their own daily maximuins. 

C. ANY "OTHER INSURANCE" IS IRR.ELEVANT TO THE POLICY 

21. The Policy requires that JNLIC pay cash benefits "immediately" upon 

proof an insured (or their family member if applicable) was diagnosed with cancer 

or received a covered treatment, care, or other matters triggering a benefit. 

22. The sole limitations and exclusions on that obligation to pay are that: 

a. Benefits get paid only for matters that are "as a result of" 

cancer (to include "treatment" thereof); 

b. There is a 30-day waiting period in which benefits are not 

paid if cancer is first diagnosed in that time; and 

C. Benefits are not paid in relation to charitable or other 

facilities that provide gratuitous or free services, stated in 

the Policy as: "... no benefits will be paid under this policy 

unless a legal liability exists for the payment of expenses 

incurred for the treatment or services rendered." 

23. Nothing in the Policy requires actual payment for services be made by 

an insured or other person as opposed to the patient merely incurring an expense. 

PLAINTIFF'S ORIGINAL PETITION Page 7 

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24. Further, nothing in the Policy refers to other insurance or limits the 

payment of benefits to only that portion of expenses a patient may owe or pay 

themselves after their priinary health insurance plan is applied, or otherwise. 

25. The risk insured against for which cash benefits are payable is simply 

getting cancer and/or receiving treatment for which expenses are incurred; not 

whether the patient can or cannot pay or whether a provider is or is not paid 

26. As a result, the Policy is not what may be referred to as an "excess" or 

"gap" health insurance plan, which in general typically makes payments directly to 

a provider to cover only what reinains unpaid by a patient after their primary 

health insurance or government benefit (i.e., Medicare/1Vledicaid) are applied. 

27. JNLIC's Policy instead pays cash directly to a policyholder (who need 

not be the patient at all, since a dependent can be covered) when a triggering event 

occurs with no restrictions on the policyholder's use of such cash benefits and 

without regard to whether other insurance exists or a provider is ever paid. 

D. THE POLICY IS KNOWINGLY AND/OR INTENTIONALLY MISAPPLIED BY JNLIC 

28. Despite the direct cash benefits nature of the Policy, JNLIC interprets 

lang.uage in it referring to the costs charged to a patient—such as "actual incurred 

cost" or a"legal liability" for expenses—against policyholders in a way that 

systematically denies and/or underpays claims when there is other insurance. 

29. That is a false, deceptive, and bad faith tactic that JNLIC uses to 

deceive, mislead, confuse, and avoid or delay paying benefits to policyholders. 

PLAINTIFF'S ORIGINAL PETITION Page 8 

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30. JNLIC is aware of the duty to act in good faith and deal fairly with 

policyholders, and aware that ambiguous terms are construed in their favor. 

31. Further, it is anticipated discovery will reveal JNLIC has received 

prior complaints—directly and/or through state insurance regulators and other 

sources—about its improper interpretations and others described herein. 

32. It is further anticipated that discovery will reveal JNLIC (itself and/or 

through its predecessors) did not always interpret or apply the cancer policies in 

these ways, but rather started doing so as a means to increase profit or cut costs. 

33. JNLIC thus knowingly and intentionally engages in false, deceptive, 

misleading, bad faith, and unfair conduct towards the holders of cancer policies. 

34. JNLIC's conduct is carried out on a uniform basis through its (and/or 

its affiliates') corporate policies, practices, and procedures. 

D. JNLIC'S CLAIMS PROCESS IS ALSO DESIGNED TO DELAY AND DENY 

35. When a person seeks benefits under a cancer policy administered by 

JNLIC, they face an arduous road ahead designed to weed out as inany claims as 

possible, without regard to validity, simply by making it unnecessarily burdensome 

nearly every step of the way to get a claim fully submitted and processed. 

36. To start, there is no website or other convenient way for a policyholder 

(or their family, friends, or caregivers if a policyholder is the one battling cancer) to 

determine who to contact or where to submit a claim, nor to find the forms to 

complete up front to miniinize processing delay, which is not industry standard. 

PLAINTIFF'S ORIGINAL PETITION Page 9 

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37. For those able to figure what number to call, JNLIC then directs them 

first through foreign call centers—staffed with persons who do not speak English in 

a familiar way and that have only rudimentary information about the Policy or its 

benefits—to field inquiries. It can take hours on the phone to get through, if ever, to 

someone based in the United States with any real knowledge 

38. A policyholder is then sent forms by mail only that require several 

more submissions before a claim will be considered, including: a physician's 

statement, medical report, and authorization for JNLIC to obtain information from: 

"... any licensed physician, medical practitioner, pharmacist, 

hospital, clinic, other medical or medically related facility, 

federal, state or local government agency, insurance or 

reinsuring company, consurner reporting agency or employer 

having information available as to diagnosis, treatment and 

prognosis with respect to any physical or mental condition 

and/or treatment of [the policyholder or dependent], and any 

non-medical information about [the policyholder or 

dependent] ." 

(the "HIPAA Authorization"). Yet, as noted further below, JNLIC never actually 

intends to use such authorization to help a claimant obtain benefits (as opposed to 

challenge them); it is just another burden for a claimant to meet to submit a claim. 

39. That is the process merely to get started for diagnosis benefits as well; 

it becomes increasingly more difficult if seeking other benefits under a policy. 

40. For example, after providing a doctor or hospital bill for cancer therapy 

(i.e., radiation, chemotherapy, or immunotherapy) or other benefits that are based 

on cost, JNLIC takes its time to process then mail a letter back stating the claimant 

must submit an explanation of benefits ("EOBs") from other insurance providers 

PLAINTIFF'S ORIGINAL PETITION Page 10 

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(with the only option offered being by mail in printed format, with postage and 

other associated costs of obtaining, copying, and mailing materials). 

41. That JNLIC does even though iiothing in the Policy refers to other 

insurance or payors, thereby inappropriately increasing the costs of submitting 

materials and delaying the processing of a claim and, otherwise, ending all 

investigation and denying a claim if other insurance EOBs are not provided, 

42. In addition, if the claim involves surgery, a hospital stay, attending 

physician visits, or related matters, then JNLIC mails a further letter—only after 

the previous iteration sent to request EOBs, to create further delay and opportunity 

to deny a claim if not provided—that requires abstruse forms and documents be 

gathered and submitted for a claim to be processed, such as: 

■ "UB-04" 

■ "CMS-1500" 

■ Operative reports 

43. Policyholders are not fainiliar with those materials and do not typically 

receive such materials in the ordinary course of care (unlike bills or other insurance 

EOBs), nor do they know where to acquire such materials. That puts another hurdle 

in the way of a claimant with more time and expense involved to figure out what is 

sought and where to obtain, and to get copies and incur more mailing expense. 

44. At no time in the process does JNLIC seek to obtain information 

directly from a provider or other person; rather, JNLIC mails letters requiring the 

policyholder to provide such material and closes a file if not done, even though 

JNLIC is aware there is a diagnosed cancer requiring treatment. 

PLAINTIFF'S ORIGINAL PETITION . Page 11 

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45. In particular, JNLIC does not use the HIPAA Authorization it procures 

in the beginning to contact billing or admin departments (or others who would be 

familiar with such materials and can provide) and request the information sought. 

46. JNLIC's failure to utilize its HIPAA Authorization to obtain any 

information after being provided with one and then bills and/or EOBs showing 

treatment that identifies the provider is a breach of its duties to conduct a 

reasonable investigation and assist a policyholder to obtain benefits. 

47. Even if a policyholder is able to figure out on their own where to 

acquire the unfamiliar materials sought and get them submitted, JNLIC then 

exploits a policyholder's lack of knowledge about billing codes and medical 

terminology to a grossly unfair degree by selectively picking out information upon 

which to deny a claim, to the exclusion of other information that supports a claim, 

and without ever providing a reasonably understandable written explanation. All 

JNLIC sends is its own "explanation of benefits" with brief references and incorrect 

or misleading numbers and figures to obscure the basis for its decisions (both on 

payments, underpayments, and denials). That is done to discourage persons from 

questioning a determination or further seeking benefits. 

48. JNLIC also does not inform claimants of other benefits they may be 

entitled to under the Policy unless a specific inquiry is made, even when the 

company already has information to determine benefits are due. 

49. For example, JNLIC has a policyholder's address on file and can tell 

from a claim form—as well as bills or insurance EOBs after that—whether or not 

PLAINTIFF'S ORIGINAL PETITION Page 12 

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the policyholder's provider is more than 50 miles away. Yet, JNLIC does not inforin 

a policyholder they may be entitled to a transportation benefit (with the forms in 

the beginning not giving a claimant an option to claim or notice either). 

50. The iterative sending of letters and requiring response by mail with 

requests for ever more material is unnecessary, increases the costs and time spent 

by policyholders, and is by such means also designed to extend the processing 

period and delay payment, while also knowingly resulting in valid claimants giving 

up in the process (or, worse, passing away from cancer in the meantime), so as to 

allow JNLIC to close a file without having to pay cash due under the Policy. 

51. All this JNLIC does while fully aware the persons seeking benefits are 

either battling cancer themselves or dealing with it in a close family inember. 

D. DEBRA VEALE IS A LONG-TIME HOLDER OF A CANCER POLICY 

52. In 1989, Debra Veale was an elementary school teacher in the Aiina 

Independent School District who was presented with the option to purchase a 

cancer treatment policy from Great Ainerican Reserve Insurance Company, as part 

of her employer's slate of benefit offerings. 

53. She was persuaded to buy fainily coverage (and add "dread disease" 

and "intensive care" riders, which are not limited to cancer) and accordingly, on 

November 1, 1989, issued a guaranteed renewable Policy (# A1096860) for a 

premium of $24.99 per month. See ]Exhibit 1. 

54. 1VIrs. Veale dutifully paid the premium ever since, for decades. 

PLAINTIFF'S ORIGINAL PETITION Page 13 

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E. 1VIRS. VEALE'S HUSBAND GETS STOMACH CANCER IN 1993. 

55. In December 1993, Mrs. Veale's husband—Hugh Veale, who was also a 

teacher and football/track coach—was diagnosed with stomach cancer. 

56. Mrs. Veale did not recall at that time that she had a cancer policy with 

dependent benefits, so did not make a claim on the Policy for that cancer. 

57. Eventually she later realized the Policy covered her husband and 

submitted a claim for benefits. To her recollection, Conseco (as JNLIC was then 

known) denied initial diagnosis benefits on the basis it was not timely sought, but 

did pay certain treatment benefits that Hugh Veale later underwent for stoinach 

cancer (which recurred at least once in the years thereafter). 

58. The stomach cancer was eventually beaten and Hugh Veale became 

cancer free in that area. 

F. DECADES LATER, 1VIRS. VEALE'S HUSBAND GETS PANCREATIC CANCER. 

59. Nearly thirty years later, on or about February 3, 2022, however, Hugh 

Veale was unfortunately diagnosed with pancreatic cancer—which was unrelated to 

the prior stomach cancer—after a biopsy at UT Southwestern in Dallas, Texas. 

60. Over the course of a year, he would undergo numerous in- and outpatient treatments for pancreatic cancer which included chemotherapy, 

hospitalization, surgery, anesthesia, blood costs, attending physicians, prescription 

PLAINTIFF'S ORIGINAL PETITION Page 14 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 18 of 76 PageID #: 44
drugs, and numerous instances of traveling more than 50 miles back and forth from 

his home in Grayson County (Van Alstyne and later Sherman) 5 to the Dallas area. 

61. Mrs. Veale was there to support her husband through his new battle 

with cancer, and sought the benefits promised by "THE CANCER FIGHTER" 

Policy, but has had to battle against JNLIC as well nearly every step of the way. 

(i) Diagnosis Benefits - Mrs. Veale Gets the Run Around for 

Months Until a"Payment" from 1997 Magically Appears. 

62. 1VIrs. Veale contacted JNLIC by phone within days of the new 

pancreatic cancer diagnosis to promptly seek all benefits available this time around. 

63. JNLIC acknowledged her notice by a letter dated February 7, 2022, 

which provided a proof of loss form titled "Claimant's Statement Cancer Insurarice 

Only" that she was directed to complete and further submit a signed physician's 

statement, HIPPA Authorization, and pathology report. 

64. On February 18, 2022, Mrs. Veale mailed the claim form, which 

disclosed her husband's stomach cancer in 1993, back to JNLIC for processing. That 

mailing included a signed physician's statement along with a report showing Hugh 

Veale had, on February 3, 2022, underwent: (1) an "endoscopic ultrasound-guided 

fine needle aspiration" ("EUS-FNA") that resulted in a positive diagnosis of 

pancreatic "adenocarcinoma," (i.e., cancer), which was further determined not to be 

5 Mr. and Mrs. Veale resided in Van Alstyne, Texas, when Hugh Veale was 

diagnosed with pancreatic cancer. They experienced a fire in that home in August 

2022, however, that required them to stay in temporary lodging for a few weeks 

before moving to a new residence in Sherman, Texas. Both locations were more 

than 50 miles from the cancer treatment facilities in the Dallas area. 

PLAINTIFF'S ORIGINAL PETITION Page 15 

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a"metastasis" of his prior stomach cancer; and (2) a colonoscopy that removed a 

tubular adenoma (i.e., a precancerous polyp). Id. 

65. Both Mr. and Mrs. Veale signed the authorization forms giving JNLIC 

all permission it sought to directly obtain health information from any physician, 

hospital, insurance company, government agency, or otherwise. Id. 

66. Starting approximately two weeks after she mailed the forms and 

continuing on nearly a weekly basis thereafter, Mrs. Veale began calling JNLIC's 

designated phone number to inquire about the diagnosis benefits in particular, only 

to be repeatedly told there was no update to give. 

67. About a month later, Mrs. Veale received a check from JNLIC dated as 

of March 13, 2022, for $75.00. She was expecting significantly more in diagnosis 

benefits and so kept calling regularly but was again told there was no update. 

68. On or about March 24, 2022—more than a month after the proof of 

cancer diagnosis was submitted and without written explanation—a representative 

of JNLIC called to tell Mrs. Veale her claim for diagnosis benefits was denied on the 

basis it was paid once already in relation to the prior stomach cancer. 

69. Mrs. Veale disputed that, recalling diagnosis benefits were denied in 

the 1990s on the basis her claim was not tiinely submitted, and that only some 

subsequent treatment or doctor bills were paid in relation to that other cancer. 

70. The phone representative acknowledged her dispute and told Mrs. 

Veale the claim would be resubmitted as a result. 

PLAINTIFF'S ORIGINAL PETITION Page 16 

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71. When she called several days later to check on status again, however, 

Mrs. Veale was contradictorily told she must instead mail in a written appeal. 

72. On April 1, 2022, Mrs. Veale mailed a letter explaining she was denied 

diagnosis benefits in the past and requesting proof of aiiy prior payment as claimed. 

73. Mrs. Veale again periodically called after mailing that letter and was, 

as usual, told no update was available, until her call on April 27, 2022, when a 

representative said proof of the prior payment would be sent to her. 

74. After waiting a week with nothing arriving in the mail, Mrs. Veale 

called again on May 3, 2022, and was contradictorily told then that JNLIC would 

not provide proof of payment because it did not keep records that far back. 

75. That was a false or misleading statement which is anticipated to have 

been made to conceal that JNLIC's records did not support a prior payment of 

diagnosis benefits as claimed (or, at minimum, revealed an underpayment). 

76. Mrs. Veale called again on May 12, 2022, and the phone representative 

reported that JNLIC suddenly found a$1,425.00 payment made on August 12, 

1997, but still would not commit to provide proof of the payment. She reasonably 

demanded to see proof as she specifically recalled being denied the benefit, but was 

told her only recourse was to again mail an appeal to the claims department. 

77. On May 13, 2022, she sent a second letter to JNLIC as directed 

appealing in writing the denial, explaining once again the course of events as she 

recalled and further highlighting a payment of $1,425.00 in diagnosis benefits in 

PLAINTIFF'S ORIGINAL PETITION Page 17 

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August 1997 did not inake mathematical sense due to the number of inonths the 

Policy would have been in effect for a cumulative benefit. 

78. She did not herself receive further response from JNLIC. 

79. Throughout those several months of seeking diagnosis benefits, Mrs. 

Veale was consistently routed in the first instance to a foreign call center with 

representatives who did not speak English in a way she could understand well, and 

had to request to speak with a US-based representative, spending hours on the 

phone waiting and in great frustration. She also had to make copies of materials 

and incur the time, costs, and burden of sending them through the inail each time. 

80. The process was mentally and emotionally draining and distressing, 

more so given her husband was suffering from cancer at the same time, of which 

JNLIC was aware given the initial notice and subinissions made. 

(ii) Denial of Treatment Benefits - JNLIC Employs ats "Other 

Insurance" Ruse to Deceive, Delay, and Deny. 

81. While Mrs. Veale was laboring to get information from JNLIC 

concerning the diagnosis benefits, her husband began the fight back against 

pancreatic cancer by a course of chemotherapy treatments starting in March 2022. 

82. Mrs. Veale sought benefits under the Policy for that as well. 

83. On May 16, 2022, she mailed in a detailed bill from UT 

Southwestern—including specifically the "Simmons Comprehensive Cancer 

Center"—for cancer treatments and care froin diagnosis to the beginning of May 

PLAINTIFF'S ORIGINAL PETITION Page 18 

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2022, which encompassed four chemotherapy sessions6 and related visits. That -bill 

identified each provider (including the doctors by name), each date of service, billing 

codes, related billing description detail, and the amounts by each line item, which 

totaled more than $89,000 in costs charged to the account of Hugh Veale.7

84. No further information was necessary for a reasonable insurer to 

determine cash benefits were due for a Chemotherapy Benefit, as well as 

Transportation Benefits for mileage to and from the address on file to the providers 

and treatment facilities in the Dallas area, for each date listed. 

85. Yet, JNLIC knowingly and intentionally failed to "immediately" pay all 

benefits due as required by its Policy and, in doing so, breached the contract, 

violated its duties of good faith and fair dealing, failed to make timely decisions or 

prompt payment, and further engaged in deceptive trade practices that include 

knowingly and intentionally misleading its long-time policyholder. 

86. That JNLC did first by employing the false and misleading ruse of 

seeking to recast its Policy as excess or gap insurance that is limited to paying only 

what costs remained after "other insurance" paid or adjusted the hospital bill. 

87. Indeed, in the first substantive correspondence on the matter, dated 

June 1, 2022, JNLIC sent a letter in the mail stating it would not consider Mrs. 

6 The initial four chemotherapy sessions occurred on or about March 13, March 25, 

April 15, and April 28, 2022, with other appointments and travel required for 

related doctor visits, bloodwork and injections in a chemotherapy course of 

treatment, as well surgical procedures related to the pump. 

7 In addition, the bill showed amounts adjusted and payinents by other insurance 

after the costs and charges were incurred, and the balance then due. 

PLAINTIFF'S ORIGINAL PETITION Page 19 

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Veale's claiins for treatment benefits without first receiving "Medicare Explanation 

of Benefits/other insurance Explanation of Benefits" showing "actual incurred 

expenses (arnount left after the other insurance paid) for ... diagnostic lab 

expense and ... chemotherapy expenses." (emphasis added). See Exhibit 2. 

88. Nothing in that letter mentioned a Transportation Benefit; JNLIC did 

not process that benefit or inform Mrs. Veale she may qualify for such benefit. 

89. Mrs. Veale called JNLIC soon after receiving the letter requesting 

other insurance EOBs and questioned why that was needed. The phone 

representative had no answer and said it would be referred to the claims handler. 

90. She called again on June 15, 2022, and was told another letter was in 

the mail. Mrs. Veale recalls the person she got through to at that time being 

particularly rude, evidently for continuing to call and question the matter. 

91. Two days later, Mrs. Veale received a letter dated as of June 9, 2022, 

which further cited the inapplicable free or gratuitous exclusion, stating as follows: 

_......,........ . . ~....~..M.. . ~_.....~....~__. _ .-~ . ,,_...., ..... . _ ..._.... .~.... _ 

This is fn response tts your appeal on the above li.sted clai.m. Your ; 

policy states "No benefits wi11 be paid under this policy unless a' 

legal liability euists for the payment of expenses incurred for 

the txeatrnent of services randered." So, i! othar instira.nca hass 

paid yAur proviclers, there are no expenses incurred Eor this 

insurance polticy. 

~ 

See Exhibit 3. The assertion no benefits were due "if other insurance has paid 

your providers" revealed a pre-determined intent to deny and/or underpay. It 

further was a knowing and intentionally false representation of the Policy terms 

and facts, designed to mislead Mrs. Veale into giving up on seeking full benefits. 

PLAINTIFF'S ORIGINAL PETITION Page 20 

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(iii) Mrs. Veale Engages Counsel to Assist; JNLIC Proceeds to 

Carry Out its Bad Faith Denial. 

92. Mrs. Veale thereafter found it necessary to engage an attorne,y as she 

was being rebuffed herself on nearly all fronts in seeking benefits under a Policy for 

which she had been paying monthly premiums for over 32 years. 

93. The initial law firm she engaged, MT2 Law Group, sent a letter to 

JNLIC on June 22, 2022, requesting payment of a full diagnosis benefit (and those 

involving treatment as well), noting in particular that JNLIC had been requested to 

send proof of any prior payment it claimed was made but none was ever provided. 

94. JNLIC did not initially respond to that legal correspondence and 

instead continued sending letters directly to Mrs. Veale. 

95. Nearly a month later, on July 19, 2022, JNLIC finally acknowledged 

her legal representation by a fax sent to the law firm demanding that attorney 

provide written authorization from Mrs. Veale within five days. 

96. In the meantime on that same day, July 19, 2022, JNLIC called Mrs. 

Veale directly to try and engage her in regard to the disputed matters. That appears 

to have been an improper effort to circumvent her counsel. 

97. The authorization for the attorney was faxed back that day. 

98. On Jul,y 20, 2022, JNLIC provided, for the very first time, a written 

explanation for its denial of diagnosis benefits—to the attorney—stating: 

I hiti is in respone to your correspondencc clated Jwne 22. 2022. Qur recotda slinw that the Initial 

Occurretice benetit of $750.00 wzts previnusly pttid for l Iu;., "h Veale on Au-ttst 12. 1997, based 

on a cliagnosi;: nit'tde on J3cccniher I=1. 1993. The Positive laiatgnosis 7"est benet"it was als<a paid t►t 

f that time. These btneFts are payable once pc;r instired. 

PLAINTIFF'S ORIGINAL PETITION Page 21 

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See Exhibit 4. JNLIC notably omitted mention of the "cumulative" benefit and still 

did not provide a copy of any "records" it claimed to have showing payment 

occurred, despite multiple requests made by that time. 

99. That was a further effort by JNLIC to conceal its own records did not 

show a prior payment of full diagnosis benefits as previously represented. 

100. On July 21, 2022, Mrs. Veale sent Medicare summaries and other 

insurance EOBs as requested (unnecessarily) by JNLIC in relation to the 

chemotherapy, hospital stays, and other treatments up to September 2022. Those 

included proof of another chemotherapy sessions that occurred in the meantime, 

with related doctor visits, as well as a hospital stay in May 2022. 

101. JNLIC then finished off its pre-determined path of denial using the 

"other insurance" ruse by, on August 12, 2022, further denying chemotherapy 

benefits because "... Medicare paid at 100%." See Exhibit 5(emphasis added). 

102. That was another false, misleading, bad faith, and deceptive act. 

103. On that same date, August 12, 2022, JNLIC also began executing its 

other tactic for delaying and denying benefits by a letter sent to Mrs. Veale seeking 

further iterative and unnecessary information; specifically, a"copy of form UB-04" 

and "CMS-1500/bill" listing "diagnosis code(s)" in relation to processing benefits 

sought for the hospital stay from May 20 to 1VIay 25, 2022. 

104. JNLIC made no effort to obtain such material from the cancer center it 

already knew was involved, even though it had a HIPAA Authorization to do so. 

8 That additional chemotherapy session occurred on or around 1VIay 13, 2022. 

PLAINTIFF'S ORIGINAL PETITION Page 22 

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105. Rather, JNLIC did nothing to assist its policyholder of more than three 

decades—in the midst of dealing with a spouse's cancer—obtain any information, 

and thereafter was content to simply deny the hospital-related benefits on 

September 21, 2022, on the basis that no materials were provided by 1VIrs. Veale. 

106. In the meantime, 1VIrs. Veale sent another detailed bill she received 

from UT Southwestern with line items showing more than $198,000 in additional 

costs charged to the account of Hugh Veale for cancer treatments through July 2022 

(with him spending much of the entire month of July in the hospital).9

107. The sole additional matters JNLIC accepted and paid from that bill 

was for a July 6 to July 10 hospital stay for surgery on his pancreas, anesthesia, 

some blood costs, and prescription drug maximums (as well as certain daily rates 

for subsequent readmissions to the hospital—on July 11, 2022, and July 25, 2022—

due to complications from the pancreatic surgery, but only under a separate 

Intensive Care rider that did not depend on cancer treatment). 

108. That brought the total amount JNLIC paid on its Policy as of 

September 21, 2022, to $7,026.00, in relation to over $280,000.00 in charges. 

109. Incredibly, JNLIC at the same tiine declined to pay other benefits for 

even the July 6 surgery (which was known already to be for cancer) on the basis 

9 Hugh Veale was admitted to UT Southwestern from May 20-25, 2022, due to 

chemotherapy-related problems; from July 6-10 for cancer surgery; readmitted soon 

after that discharge and stayed from July 11-20 due to complications from surgery; 

and once again readmitted from July 25-29 for further issues related to the surgery, 

in which he also underwent a surgical endoscopic procedure. 

PLAINTIFF'S ORIGINAL PFTITION Page 23 

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that JNLIC supposedly still needed "pathology" and "operative" reports to 

determine if any other cancer-related benefits were due. See Exhibit 6. 

110. JNLIC also avoided paying benefits for the other hospital stays in July 

2022—other than intensive care previously noted—on the basis again of supposedly 

needing "UB-04" and "CMS-1500" forms to determine if benefits were due. Id. 

111. Such materials were unnecessary as it was already clear from the 

billing forms and other information provided that all the matters involving UT 

Southwestern were for cancer treatment. JNLIC's actions thus were undertaken to 

be difficult, delay and/or search for select information to avoid payment. 

112. And further, once again, JNLIC failed to itself obtain anything it 

sought from the hospital, putting all onus on Mrs. Veale to do so in the midst of 

caring for and supporting her husband through an intense battle with cancer. 

113. Indeed, on October 27, 2022, JNLIC closed its file without obtaining 

any information itself or making any payrnents due for the various hospital stays in 

July 2022 on the basis it did not receive from Mrs. Veale the additional materials it 

knew that policyholders are not ordinarily given. See Exhibit 7Pe. 

114. JNLIC also continued failing to process or inform 1VIrs. Veale of any 

Transportation benefits (which consisted of mileage but not lodging, since Mrs. 

Veale stayed in the hospital with her husband while he battled cancer). 

(iv) JNLIC Changes Course, in Parrt, Only Due to a Regulatory 

Inquiry by the Texas Department of Insurance. 

115. Thereafter, Hugh Veale was able to recover from the surgery 

complications enough to resume his chemotherapy course of treatment. 

PLAINTIFF'S ORIGINAL PETITION Page 24 

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116. Mrs. Veale sought new counsel in the meantime because the attorney 

from the original firm she engaged was planning to retire from active law practice. 

117. Her current undersigned counsel was engaged and spent substantial 

time reviewing and analyzing the iterative correspondences and vague explanations 

by JNLIC (for both the payments made and denials), the insurance Policy, 

submissions of numerous bills, forms, and EOBs that JNLIC required, the 

applicable law, and other legal work to prepare a comprehensive notice of violations, 

as well as prior notice of this potential class action if JNLIC did not change its 

course of conduct (the "Notice").

118. The Notice requested that JNLIC pay Mrs. Veale a specific amount of 

economic losses, mental anguish, and attorney's fees, as well as provide written 

assurances all the improper conduct in delaying and denying payments would cease 

both as to Mrs. Veale individually and all others similarly situated. 

119. That Notice was sent to JNLIC on January 18, 2023, along with 

submissions of additional Medicare summaries that became available showing three 

more chemotherapy sessions and related treatments/visits.10

120. A copy of the Notice was sent also to the Texas Department of 

Insurance ("TDI"), which got involved to request a response from JNLIC. 

121. Only then—due apparently to regulatory inquiry—did JNLIC suddenly 

become willing to provide more information and explanations (only to TDI though, 

lo Those sessions occurred on or around June 3, Sept. 14, and Sept. 27, 2022. 

PLAINTIFF'S ORIGINAL PETITION Page 25 

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with that agency's intervention needed to get JNLIC to provide the saine 

information to Mrs. Veale's counsel), and to make partial payments long past due. 

122. In the process, JNLIC was forced to finally reveal that it did not have 

proof of a proper payment of initial diagnosis or cumulative benefits. 

123. Further, JNLIC continued to deny portions of cash payments well past 

due for nearly all other categories of benefits available under the Policy, including 

chemotherapy, hospital stays, surgical procedures, anesthesia, attending physician 

visits, prescription drugs, blood costs, and transportation benefits (not to mention 

failing to pay the full amount of statutory interest due), each in an amount which 

exceeds the jurisdictional prerequisites of this Court. 

124. That specifically included (but is not liinited to) failure to pay for all 

costs charged for substances, injections, and other services in the chemotherapy 

course of treatments, which JNLIC did without any explanation. 

125. In addition, after apparently obtaining "UB-04" and/or "CMS-1500" 

forms, JNLIC proceeded to further deny payment of certain hospital-related 

benefits on the basis that a single "diagnosis code" on one form was not specific to 

cancer, which willfully ignored other codes and the full context of all information 

which already confirmed all services were "as a result of' cancer treatment. 

126. On March 20, 2023, after further Medicare summaries and insurance 

EOBs became available, proof of three more cheinotherapy sessionsll and related 

treatment/visits were submitted to JNLIC for payment. 

11 Those sessions occurred on or around Oct. 25, Nov. 17, and Dec. 2, 2022. 

PLAINTIFF'S ORIGINAL PETITION Page 26 

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127. As of the date of this filing, over a month later, however, JNLIC has 

not paid on the recent submission even for the same portion of expensea paid in 

response to TDI's inquiry, and thereby continued and/or resumed breaching its 

duties and obligations to act in good faith, deal fairly, and make prompt payment. 

128. JNLIC thus continues to act in bad faith, breach the contract, engage 

in deceptive trade practices, and commit other violations of law, and has given no 

assurances of ceasing its improper conduct as to future claims of Mrs. Veale or 

others similarly situated, absent relief being granted by this Court. 

129. All conditions precedent have been performed or occurred. 

CLASS ALLEGATIONS 

130. All preceding paragraphs are restated in full. 

131. Plaintiff Debra Veale seeks to recover on her own behalf and further 

brings this action as a representative on behalf of the following proposed classes: 

The "Nationwide Class": All holders of a cancer treatment 

policy with or administered by Jefferson National Life 

Insurance Company within the past three (3) years who have 

in that time been denied or paid less than the full costs they 

subrnitted for cancer treatment on the basis that all or part 

of the costs were paid or adjusted by other insurance. 

The "Texas Subclass": All holders of a cancer treatment 

policy with or administered by Jefferson National Life 

Insurance Company within the past three (3) years who 

resided in the State of Texas and have in that time been 

denied or paid less than the full costs they submitted for 

cancer treatment on the basis that all or part of the costs 

were paid or adjusted by other insurance. 

The "Nationwide Chemotherapy Subclass": All holders of a 

cancer treatment policy with or administered by Jefferson 

National Life Insurance Company within the past three (3) 

PLAINTIFF'S ORIGINAL PETITION Page 27 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 31 of 76 PageID #: 57
years who have in that time been denied or paid less than 

the full costs submitted for all substances injected, items 

used, or services provided during a chemotherapy course of 

treatment. 

The "Texas Chemotherapy Subclass": All holders of a cancer 

treatment policy with or administered by Jefferson National 

Life Insurance Company within the past three (3) years who 

resided in the State of Texas and have in that time been 

denied or paid less than the full costs submitted for all 

substances injected, items used, or services provided during a 

chemotherapy course of treatment. 

The "Nationwide Failure to Investivate Subclass": All holders 

of a cancer treatment policy with or administered by 

Jefferson National Life Insurance Coinpany within the past 

three (3) years who have in that time been denied payment of 

any benefits for cancer treatment on the basis that a 

policyholder failed to submit Form UB-04, CMS-1500, or 

medical reports, after having already provided a HIPAA 

Authorization. 

The "Texas Failure to Investigate Subclass": All holders of a 

cancer treatment policy with or administered by Jefferson 

National Life Insurance Company within the past three (3) 

years who resided in the State of Texas and have in that time 

been denied payment of any benefits for cancer treatment on 

the basis that a policyholder failed to submit Form UB-04, 

C1VIS-1500, or medical reports, after having already provided 

a HIPAA Authorization. 

132. Excluded froin each of the above classes are officers, directors, or 

employees of JNLIC, the company, its affiliates, or its legal representatives, heirs, 

successors, and assigns, and any Judge to whom this case is assigned and his or her 

immediate family. 

133. The foregoing definitions may be expanded or narrowed based on 

additional information obtained through investigation, discovery in this proceeding, 

or as may otherwise occur in the course of this action. 

PLAINTIFF'S ORIGINAL PETITION Page 28 

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134. The Nationwide Class, Texas Subclass, Nationwide Chemotherapy 

Subclass, Texas Chemotherapy Subclass, Nationwide Failure to Investigate 

Subclass, and Texas Failure to Investigate Subclass are hereinafter individually 

and collectively referred to as the "Class."

135. The members of the Class are geographically dispersed and so 

numerous that individual joinder is impracticable. Although the precise number of 

Class members is unknown to Plaintiff at this time, the exact number of Class 

members is known to JNLIC. Specifically, JNLIC (and/or its affiliates or contractors 

on its behalf) maintain databases and other records that contain the following: (i) 

the name of each Class member; (ii) the last known address and other contact 

information of each Class member; and (iii) each Class member's claim file. Thus, 

all Class members may be identified through discovery and notified of this class 

action by first class mail, electronic mail, and/or published notice. 

136. This action accordingly has been brought and may properly be 

inaintained as a class action because there is a well-defined community of interest 

in the litigation and the proposed Class is readily ascertainable. 

137. Common questions of law and fact exist as to all members of the Class 

and predoininate over individual questions, as proof of a common set of facts and/or 

law will establish the right of each member of the Class to recover damages. These 

common questions include, but are not limited to, the following: 

a. Whether the terms of JNLIC's insurance contract limit or 

exclude payment of costs for a cancer treatment based on 

any other insurance held by a patient or policyholder 

being applied to pay or adjust a bill; 

PLAINTIFF'S ORIGINAL PETITION Page 29 

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b. Whether the terms of JNLIC's insurance contract exclude 

payment of the costs of any substances injected, items 

used, or services provided at any time during a 

chemotherapy course of treatinent; 

C. Whether JNLIC defrauds, deceives, misrepresents, or 

misleads policyholders by stating the policy is limited to 

(or without disclosing it is treated as limited to) paying 

benefits only to the extent a cost for cancer treatment is 

not otherwise paid or adjusted by other insurance; 

d. • Whether JNLIC defrauds, deceives, misrepresents, or 

misleads policyholders by stating the policy excludes (or 

without disclosing it is treated as excluding) payment of 

the costs of any substances injected, items used, or 

services provided at any time during a chemotherapy 

course of treatment; 

e. Whether failure of JNLIC to request materials directly 

from a medical provider that are not ordinarily given to a 

patient—specifically including but not limited to Form 

UB-04, CMS-1500, and medical reports—after having 

received a HIPAA Authorization, is a breach of JNLIC's 

duty to conduct a reasonable investigation and/or assist a 

policyholder to obtain benefits; 

f. Whether JNLIC's uniform conduct as applied through its 

policies, procedures, and practices as to each Class 

member constitutes a breach of contract; 

g. Whether JNLIC's uniform conduct as applied through its 

policies, procedures, and practices as to each Class 

member constitutes a breach of the duty of good faith and 

fair dealing; 

h. Whether JNLIC's uniform conduct as applied through its 

policies, procedures, and practices as to each Class 

member constitutes fraud or negligent (or grossly 

negligent) inisrepresentation; 

i. Whether JNLIC's uniform conduct as applied through its 

policies, procedures, and practices as to each Class 

member constitutes an untrue, deceptive, and/or 

misleading assertion, representation, or statement 

PLAINTIFF'S ORIGINAL PETITION Page 30 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 34 of 76 PageID #: 60
prohibited by Chapter 541 of the Tex. Ins. Code (and/or 

similar law in other states); 

j. Whether JNLIC's uniform conduct as applied through its 

policies, procedures, and practices as to each Class 

member constitutes a deceptive trade practice that is 

prohibited by Chapter 17 of the Texas Bus. & Com. Code 

(and/or similar law in other states); 

k. Whether JNLIC's uniform conduct as applied through its 

policies, procedures, and practices as to each Class 

member constitutes a breach of Chapter 542 of the Texas 

Ins. Code (and/or similar law in other states); 

1. whether Plaintiff and the Class have sustained actual 

monetary loss and the proper measures of that loss; 

M. whether Plaintiff and the Class are entitled to increased 

statutory interest awards; 

n. whether Plaintiff and the Class are entitled to treble, 

punitive, and/or exemplary damages; 

o. whether Plaintiff and the Class are entitled to injunctive 

relief; 

P. whether Plaintiff and the Class are entitled to an award 

of attorney's fees and costs. 

q. whether Plaintiff and the Class are entitled to other 

relief. 

138. The claims of Plaintiff are typical of and have the same essential 

characteristics as the claims of all other Class members in that JNLIC uses the 

same practices, policies, and procedures as to each member. 

139. Plaintiff will fairly and adequately represent and protect the interests 

of the Class, and has retained counsel that is coinpetent and has prior experience 

with class action litigation. Furthermore, Plaintiff has no interests that are 

antagonistic to the members of the Class and has suffered the same harm. 

PLAINTIFF'S ORIGINAL PETITION Page 31 

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140. Plaintiff's counsel has spent substantial time investigating the issues, 

this class action, and representing Plaintiff in regard to these same claims against 

JNLIC, and intends to vigorously prosecute this action on behalf of and for the 

benefit of all members of the Class, with adequate resources to do so. 

141. A class action is superior to other available means for the fair and 

efficient adjudication of this controversy. The prosecution of separate actions by. 

each individual member of the Class would impose heavy burdens upon the courts 

while creating a risk of inconsistent or varying adjudications of the questions of law 

and fact that are common to the Class, and risk impairing Class members' rights or 

the disposition of their interests through actions to which they were not parties. 

Individualized litigation would also increase the delay and expense to all parties 

and the court system. Class members who purchase cancer treatment policies also 

do not have adequate individual resources to afford their own legal counsel and the 

expenses of litigation. By contrast, the class action device provides the benefits of 

adjudicating the common issues in a single proceeding, creating economies of scale, 

with comprehensive supervision by a single court. Plaintiff is not aware of any 

unusual management difficulties under the circumstances, while an important 

public interest will be served by addressing the matter as a class action. 

142. In the alternative, the Class inay also be certified because: 

a. the prosecution of separate actions b,y individual Class 

meinbers would create a risk of inconsistent or varying 

adjudication with respect to individual Class members 

that would establish incompatible standards of conduct 

for JNLIC; 

PLAINTIFF'S ORIGINAL PETITION Page 32 

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b. the prosecution of separate actions by individual Class 

members would create a risk of adjudications with respect 

to them that would, as a practical matter, be dispositive of 

the interests of other Class members not parties to the 

adjudications, or substantially impair or impede their 

ability to protect their interests; and/or 

C. Defendants have acted or refused to act on grounds 

generally applicable to the Class as a whole, thereby 

making appropriate final declaratory and/or injunctive 

relief with respect to the inembers of the Class as a whole. 

CAUSES OF ACTION 

Count I: Breach of Contract 

143. All preceding paragraphs are restated in full. 

144. The applicable cancer insurance policy is a valid enforceable contract. 

145. Plaintiff12 is a proper party to bring suit for breach of that contract. 

146. Plaintiff performed, tendered performance of, or was excused from 

performing all contractual obligations. 

147. JNLIC breached its obligations in the ways described herein to cause 

injury by failing to immediately pay the full amount of cash benefits due. 

Count II: Breach of the Duty of Good Faith and Fai.r Dealing 

148. All preceding paragraphs are restated in full. 

149. The applicable cancer insurance policy is a valid enforceable contract 

which gives rise to a duty of good faith and fair dealing. 

12 Reference to Plaintiff in this Causes of Action section is ineant to also include and 

be applicable to each of the Class members. 

PLAINTIFF'S ORIGINAL PETITION Page 33 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 37 of 76 PageID #: 63
150. JNLIC breached its duties by providing false or misleading 

information, by deceptive omissions, and/or denying, delaying, or underpaying cash 

benefits after it was reasonably clear that cancer diagnosis and treatment occurred. 

151. JNLIC's breach proximately caused Plaintiff to suffer injury by the 

delay in and/or failure to receive cash benefits when due, loss of time, postage and 

other expenses, and mental anguish. 

152. JNLIC's conduct was fraudulent, malicious, intentional, or grossly 

negligent, subj ecting it to punitive or exemplary damages. 

Count III: Negligent Misrepresentation 

153. All preceding paragraphs are restated in full. 

154. JNLIC made representations to Plaintiff in the course of its business 

or in a matter in which JNLIC had a pecuniary interest. 

155. JNLIC supplied false information for the guidance of others. 

156. JNLIC did not use reasonable care in obtaining or communicating the 

information and Plaintiff justifiably relied on the representations. 

157. JNLIC's negligent misrepresentations caused Plaintiff to suffer injury 

by the delay in and/or failure to receive cash benefits when due, loss of time, 

postage and other expenses, and mental anguish. 

Count IV: Tex. Ins. Code ch. 541 

158. All preceding paragraphs are restated in full. 

159. JNLIC (itself and/or through its predecessors) is a Texas-chartered 

insurance company that issued policies from its home off"ice in Dallas, Texas, and 

PLAINTIFF'S ORIGINAL PETITION Page 34 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 38 of 76 PageID #: 64
subsequently breached duties owed to all its policyholders under Chapter 541 of the 

Texas Insurance Code (and/or similar statutes and duties in other states) by doing 

one or more of the following: 

a. Making, issuing, or circulating an illustration, circular, or 

statement (or causing any of the same to occur) that 

misrepresented the benefits or advantages promised by 

the cancer treatment policies at issue; 

b. 1VIaking, publishing, disseminating, circulating, or placing 

before the public an advertisement, announcement, or 

statement (or directly or indirectly causing any of the 

same to occur) containing an untrue, deceptive, or 

misleading assertion, representation, or statement 

regarding the business of insurance; 

C. misrepresenting a material fact or policy provision 

relating to the coverage at issue; 

d. failing to attempt in good faith to effectuate a prompt, 

fair, and equitable settlement of a claim with respect to 

which liability was reasonably clear; 

e. failing to promptly provide a reasonable explanation of 

the basis in the policy, in relation to the facts or 

applicable law, for denial of a claim; 

f. refusing, failing, or unreasonably delaying payment on 

the basis that other coverage may be available or that 

others are responsible for payment; 

g. refusing to pay a claim without conducting a reasonable 

investigation with respect to the claim; 

h. misrepresenting the insurance policy by making an 

untrue statement of material fact, or failing to state 

material facts to make other statements not misleading, 

or making a statement in a manner that would mislead a 

reasonably prudent person to a false conclusion of a 

material fact, or making a material misstatement of law; 

or 

PLAINTIFF'S ORIGINAL PETITION Page 35 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 39 of 76 PageID #: 65
i. representing an agreement "confers or involves rights, 

remedies, or obligations which it does not have or involve" 

in violation of Tex. Bus. & Comm. Code § 17.46(b)(12) that 

was relied on to Plaintiff's detriment. 

160. JNLIC's acts were done knowingly or intentionally. 

161. JNLIC's acts or practices were a producing cause of Plaintiff's damages 

and other losses. 

Count V. Tex. Bus. & Comm. Code ch. 17 

162. All preceding paragraphs are restated in full. 

163. Plaintiff is a"consumer" with rights under the Texas Deceptive Trade 

Practices Act (and/or similar deceptive trade practices statutes in other states). 

164. JNLIC committed one or more of the following wrongful acts: 

a. representing an agreement "confers or involves rights, 

remedies, or obligations which it does not have or 

involve"; 

b. an unconscionable course of conduct; or 

C. use or employment of an act or practice in violation of 

Tex. Ins. Code ch. 541. 

165. JNLIC's acts were done knowingly and intentionally. 

166. JNLIC's acts or practices were a producing cause of Plaintiff's damages 

and other losses. 

Count VI: Tex. dns. Code ch. 542 

167. All preceding paragraphs are restated in full. 

168. Plaintiff made a claim under a cancer treatnient policy. 

169. JNLIC was liable to pay the claim. 

PLAINTIFF'S ORIGINAL PETITION Page 36 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 40 of 76 PageID #: 66
170: JNLIC failed to acknowledge, investigate, accept or reject (or provide 

timely written explanation), or pay the claim within the deadlines set by Tex. Ins. 

Code ch. 542 (and/or similar statutes, rules, and law in other states). 

Count VII: Injunctiue Relief 

171. All preceding paragraphs are restated in full. 

172. Plaintiff Debra Veale seeks, on her own behalf and on behalf of all 

Class members, an injunction to prohibit JNLIC from continuing to engage in the 

~ 

unlawful practices complained of herein. Unless restrained by this Court, JNLIC 

will continue to violate the cancer treatment policies and deal with current and 

future policyholders in ways that constitute a violation of its duties under statute 

and common law, and that are deceptive trade practices, causing injury to all. 

173. Plaintiff has no other adequate remedy at law to ensure future 

compliance by JNLIC with the duties described herein. 

174. Therefore Plaintiff requests permanent injunctive relief. 

ATTORIVEYS' FEES 

175. All preceding paragraphs are restated in full. 

176. Plaintiff Debra Veale was and is required to engage attorneys to seek a 

full recovery, and is entitled to an award of all fees, costs, and expenses for breach 

of contract, see TEx. CIv. PItAc. & REM. CODE § 38.001, under the Insurance Code, see 

TEX. INS. CODE §§ 541.152(a)(1), 542.060(a), the Deceptive Trade Practices Act, see 

TEx. BUS. & COMM. CODE § 17.50(d), and counsel in this case is further entitled to 

an award of fees as a matter of equity and common benef'it to the Class. 

PLAINTIFF'S ORIGINAL PETITION Page 37 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 41 of 76 PageID #: 67
JURY TRUI. 

177. Plaintiff requests a trial by jury of all issues so triable. 

PRAYER 

WHEREFORE, Plaintiff Debra Veale requests this Court: 

■ Certify this action with each Class proposed, appoint 

Debra Veale as Class Representative, and appoint Wright 

Commercial Litigation as Class Counsel; 

■ Award all actual, economic, general, special, and other 

damages; 

■ Award treble, punitive, and/or exemplary damages; 

■ Award permanent injunctive relief against JNLIC; 

■ Award attorneys' fees, expenses, and court costs, as well 

as conditional awards in the event of an,y post-verdict 

proceedings and/or appeals; 

■ Award statutory interest under Tex. Ins. Code 

§ 542.060(a) and/or similar laws and rules in other states, 

as well as pre- and post-judgment interest as otherwise 

provided by law; 

Award all other relief, both special and general, at law or 

in equity (including expert expenses and litigation costs 

pursuant to Tex. Ins. Code § 541.152(a)(3) and Tex. Bus. 

& Comm. Code § 17.50(b)(4)), to which Mrs. Veale, the 

Class members, and/or counsel may otherwise be entitled. 

PLAINTIFF'S ORIGINAL PETITION Page 38 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 42 of 76 PageID #: 68
Dated: April 24, 2023 Respectfully submitted, 

WRIGHT COMMERCIAL LITIGATION 

By: /s/ Jason E. Wrioht 

Jason E. Wright (TX Bar No. 24063896) 

8751 Collin McKinney Pkwy, Ste 1102 #1088 

McKinney, TX 75070 

Tel: (469) 270-7819 

Fax: (469) 270-7822 

Email: jason@jwrightlaw.com

ATTORNEY FOR PLAINTIFF 

PLAINTIFF'S ORIGINAL PETITION Page 39 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 43 of 76 PageID #: 69
EXHIBIT I 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 44 of 76 PageID #: 70
[A-A 

~ i 

~. 

eftsasQilBrDC ■ E©tNpAitY 

Mor+s Oflk.a; poltaf, Teau 1'DM 

A 9tActt t:cfrvtny 

Ab01!! tftlf POYCy Tkhi-~ ptlfCy ii 0 ofXi'R;:t PIOYk6nQ IndGRlfiRy DQt10ft19 tSit b"~,'sUS tflCtRTI%1 tU A raRln Ci 

fespa :nl wdktctnam trnd oRwr 6popAvd qKperr`,oD tot dw ttCOhn" td exnCcr. As usw 

ttcir+ro, 'you' rtnd 'yrnu' monrt ths tJanod UtsustKt; 'we', 'ue', ond 'un' r+roeut flreat 

lvneriaa,-1 Rasemr_ tncurtmp Cartpiurtr• 1k'o lxr+a mnoa ttw poticy !n oortssdoa•ntion ot 

Yeuv aero ia~ ;r~E1¢ tulsrtnorn ot +ho first nrnmMme 

Oe:r PrOmteo Wo txtlml;c) to paY ttin bonmF,x dantaiDad In tha P*~+:y H Cny faturtd frursm (1) tnqn9 

©xqr~lpog, roilks~ns tro;arncnt or ottY.1•am baner: a arroeo6 tms tls ti rutWit at osnmoa; 

(?) ie IfrFt a'Cx3no:uid <ti rern; carn ±r nn or Mtce thn Etloeuva Wto at tFro pekcy; end 

(3) trtcua Ow aapecr!t+ ot tsnqrr> ttm IrCatnl^nt sehdi U:9 D~=y E3 >1 farca. We >vi:l p5y 

tha_~p,s~ri ,exiffism cer+t,knM o,> >hls EsvJ mnn: t~2sx oaasc, 

10 t?sy NJgRt 7FQS t9 A LCMITSD PDl]CY. !T IS.A 1&i3AL CMTRACT Bfi-MIEEN YOII AMD US, 

to F.xamtnn PLEASc APItD TiNIS POLICY CRl;ER1Ll.Y. N yon 2m Ps,t w-it tRis putsY Iot 

PalFcy mny lvasan, you m~.~y riwr -t to us wittillt 10 cGrya aRor you tacnira rt ond elrlein a 

tpht7l'J 6t El prn*r.141ns Fa4, YpU rtL.~^y re1ed71 IA by: (1) ITffiSstg et sp t* Ct ihq AhOra 

ttrJ*ia53: tx IrI nilmvnp M to alr tgent wh4 aC+d x tn ynal. Wo ki7 pmr+iDt1Y rett>1d eA 

t~nzm~m: w~.vra_im s.y w,n ex. ~rar:~od yg"~d tmm iin F~c~lam R:~a. 

• 

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CAKCER TAFJiTlALM IMb1yYTiNt.F PriLlCY . nUARAlREE'.0 tDtH£WApF,F, • iIENF.LYAL 

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21ti800ft09-861 P6Qt? 1 tt;►J i9•vot t •@D 

~ 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 45 of 76 PageID #: 71
TABLE OF CONiEMTS 

~ 

Pp0Cy Inforrrwtia'+........... ............ . , 

. , . ... .. . ... .. . . . . .. . . . . . . . . . . . . . . .. 3 

4~opan~nnt's ~nvecaqa Plrl 1 . . . : . . . . . . . . . . . .. . . . . . . .. . , . . . . ... .... . 5 

9enelitwrovisrons Part 2 ....................................: B 

Lmrtetwns and Exclaasions FAt19 . . ... ... ... . ....... .. . . .. . . . .... .. . 9 

Promnem, tianew:b:ity orrd 

TorTmapon Provisrn.vs Fst! A . . . ... . . . . . . . . . . . . . . . . . . . . .

(saim Piovisions PMt 6 . .. . . . . . ... . . . . . .. . . . .... . . . . . . .. L1 

QlnFif PaLy Pf{Y1dsonS Tfkb .................... . e..•.•P•..,.....:... It 

gut9ica! ychoaulo Prt.7 . ... . . .. . .... _........... ...... . . . La 

14Aeee To Flnd It . . . . . . . .. . . ... ... . .. . . .. . .. . . .. . . . . . .. . . . . . . . . . btiss" BUaK Cover 

22• y0 D t(09•86 E P"9 t 

; 

~ 

A 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 46 of 76 PageID #: 72
MMUM& IRPf•.l"F 

r,aIXF.A t86U6AZ,"r PQ»TCY L143.46 

NAts3vR: e&113R9• 90 E*AT6 

S'sfa'~. 'ICNL BL'1CUiT fAC20Bs n'.9 

lμDl'iw0.6 brwlr 1i1bLiL 

I9°'£u51VE f.hltL 21S7ft $72.09 

MeAA D358'IISG TsD`A a36.J0 

!sz►ncm• 

1tmr:4tLi ouh1"~' ..?Z6T ,ld1E-ng.-Du. :at►+'SaAL 

3i4.?r 6?l•Sf ;ISi,t4

Ak 

llCZ A7 ! 89y4t - 93 .- Pp'.2tY +WSN3CR M04LMI 

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Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 47 of 76 PageID #: 73
PC~ie'r. riUMl~i '#to4s66e 

r o L t C T E c 1i.6-o 0"t.t. 

CAtic€X 7sltu:Tla.rP IitwA.JIKC4 i4»JtT :L". kF['Fts 

;LL ;1AL D[11GM19 AL2+I"1T 

tOR YOq ........... .•....... . . 5254D 

1Y?R YOt7A 1N~1'A t1E78ttIIS>?'!3 ...................... .. ,.. 1, 250 CCt:lLA:lvte PlAS:.CCdJdCNCC tC/71T••

= T0Q .. ..............:........ .w........... . f]0 Gv, IG:h"TN 

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1A~'i1GL ' ➢sYU^i4. ` SLf+EflCtit. 

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Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 48 of 76 PageID #: 74
~ ! ~ 

PART 1. DEPEN[1!"NT'S COVERAGE 

EL1GIf31lRY 

Ttus pc=ity psoVtdns iRSutartce tra you a..'1d yrsut 

otigrbto dopundonta (if prry) named m your ong.nit 

at:pltcahon unless spoctflcoAy ozciudod 5y 

onaorsomont. Eligib7e dopnnortnts inctuda yovr: 

• sp.use; snd 

• unrnamed dlikfr0n tess ttlan 21 yovs ot aQ,i. 

'Chddron' meanr; yosr natural cnitdron, stepahiildran, adopted chddrod, ahltdrer pnnding 

Gdopttan i( fiving wqh you end any other cr,ldran fcr 

wham you aro a fegai guardittn, 

AADING DEPEiJD 

Eacept lot ctWdron tsotrt to you or a covuted 

osponoant atfoi tho Efttrc:trvo f3ato of tru, pohcy, 

rsny otVbfe depor►dont not tnsuroo on tho ENocttvo 

l]ato may bo bddod upon applrratson by you, 

paymaht of any additxml prornium and approval by 

us. Evidenco ot Insuratxtiry as we may requ~o 

mu:ut tso fumishod to as 4otoro eoverago wA begil. 

Sucn swdEMlce vrilt Otf proviUod af your e:tsenso. 

t3oponoonts so edded wdl bo covnrod only lor 

cancor fisst diagnosed 50 or moro tlays ahcr dwy 

aJ9 apptovod tor caverege oy ufl artd tho roquuad 

prem¢tm is pokd. 

fJ5W8ORt3 Cti1LOR€N 

Cnddren bom to ycu or a coverod depondant afsor 

To E-ttttitivo t]aro or thi9 poUcy wdl bo +nsured 

iCnmudratnty from .tho marnent ol urin tor a penod 

of 31 days. Covoroqt3 s.'ta.7 bo lhat providod any 

otnOr tnsurad dopandont undLY Itti! rio'.iCy. No 

aNdartco of inssrra2>ility wW bo rnqunod. 

To coritrnuo covoraQo for a n6ivtwm cndd, you 

must notlty ua af tha bsth andmn 31 dnys attor itxt 

dato ot birttt. Wa wlli than ativisse y" ol any 

ptam+um duo fcr v4jQ,t catrorego. You must pay us 

tne premturn dt :j w9tdn 15 i4tys altar rtatificatton by 

us of lho amount duo. Hovrovor, d olhor 

d!•pondants aro providea coverage under tnrs 

poliaif, you nood not nottty u5 ol tho binh in crder 

to conttnue coverago ot tnn nowoom and no 

addQional promum wi8 bo duo. 

tl a tta.m bocomas payabto lat a nuwborn ch,ld 

hetore Ine apphc,2bte prornvm is paid, wo may 

22•9Q01(09•68) Pago 5 

doducl Ih9 n+rrntttnl dur) for rho cnfld'S - overaga 

frttm Yso Denorit8 pay8bla, 

TER},11NATI0bj OF DEPEtdDENT'S COVERAGE 

It your covarag9 tarmlnoto5 as a rnsuft of your 

d2ath, your 5tr`Ou50. d tnC+t insurCd. wn;l bLconto 

f(xt Namod Insurod un;ter tho pohey. Ctherwieo, 

ccvetcaa on any dopondoM wi:t ltlrminplo On tne 

sc6ner of: 

• Itto tlata yG:ir GOYer3qu fOrmSta:nB; 

• 31 dIIya attAr any p+amruan duo dato it tha 

Ivomwm is unpaid; 

e with rospect lo your spause. ttto dato of 

divoreo, annutmant of rnorriogo or logal 

soparantxt; 

• w,th rDsvoct to n9wootn Crnldroft. 31 days dttor 

Ine dato of l:,rth. un4oss wo ato noh!iod ot tho 

tunh and any awicafita protrnum is ptwd, a9 

peowefod b1 iho 'Rtowbom Chddron' provision; 

W 

• t5ith rUsPOCt 10 othgr dopend9nl crtldrbn, 1310 

dato rhoy 3ttII11 aQo 21 ~1 m21ry, i! s00l1er, 

subject ro ttue 'Cononuacon at Covorat,p Far 

Cenan 17oaondonta• provision. 

Ftowevar, d wo acccpl a promtum applrcaW.o who:ly 

ot itt part t1X a ptlt7Qd past ItW [}rrttr CpVurago woutd 

otherwiso torminato according lo tho nbove, 

cnverago witt cortcinuo during tfita pnrtod for vrhich 

tho p<emFurn was accop:Od. 

TCtmmanon ol coverago she_9 not attect any CIAUtf 

or loss commencirig pnaa thnrnto. 

CONTINL)A_TlfllJ OF COYt:pAGE FOR CERTAIN 

D@PENOENT9 

Cusp4o ony ot tho anovo, covorago tor oRy 

unrn, mod, dupeailent ahUd rnay lio contrnuad pa ,t 

ago 21 it; 

a tho chi3d is inccpab;o of sall•support dua lo a 

chysical or menral herutir—apc 

• sucn inctAat7ty stanrjd prior 10 A9e 21 whdo 

.nsured under this poacy; 

• a roquast tor continuation anti saaslactnry 

proot ol Ine cndd's incaWry is recerveo oy us 

ICN 24•t)011•01 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 49 of 76 PageID #: 75
wrlhtn 31 CayS lfl0r t:Lvetil$o Wotilp 9ttterwr5o 

turrnir+ato: tarid 

• eny rr3,;uNed prntnarnt is pad. 

TN prEjmvm 5hap tyt% tttiit witiCh wGult2 f>s7v® tyeen 

cnorged on tttt7 dato covorage vrould have 

Otfl9tYet59 trtrmsTl:tiiN!. 

LYe have ttte right onct each yetar to roqu re prool 

ol tng et+o's eontmeany rr>`apoeity. Coveraqe 

cootvu,od under b'es provitsron ws tarntutatp ort the 

soanet of: 

• lno daid rhe cttitd i8 ne Fongo! mcilpilcitotoo: 

• t7o Hromroum ©uo Oato lo;fotiring ou+ reotm,t 

for proDf - o1 4onpnuod i2►GRpr,Cty rl wcn proot 

rs not tumtahod; or 

• ttw dalo ywr covoiage termtriotos 

COMW6aS Ic3Pd 

nny doaarldm*t vrtiosp Covor.K}e ur.dar ttur; po►cy 

lCrrn•nat85 tO+r any reO.Spn o1R9P th.lit nanp„ytil&nt 

ot prem!um shafl have !Ro naht 10 appty tar ;r.g 

reco+vA a pottcy provrding :~mttar bertafitrr. ^ta 

pvrdonr;e ol rnsuratp9ity rrili ba roquvted d the 

applrcaaan i-r1C poyrtmnt ot lhe first prermum lor the 

new poLty ara rucewad by us w.lhin 31 days oftar 

tomunahon of covarogo unrdzr tttis policy. 

The nen poftcy rvr<g tako oftoct on IMi dsy foEtornrx] 

iCretrar►3Coft" Ot covelt3go UndRf inlS pObCy. 11t{r .now 

pot,cy, v.-Al not covr# anv loss fAr wnch bonohts uo 

geyabb under ltsis pohry. Any exdusion ponods. 

wadsrtg Fensds cr Qgriods dutinq wttich wo can 

contErst covorago twll bo meraaured trom tno 

A19eGtrrO dit9 ef trii8 poticy. 

Tile prem,um wdt be based on tho agn af It,N 

tlBpflM1dcAl Jnd otlr r7toS In 4ffect Qrt the dWto Iho 

nomr policy ia iS,ued. 

PART 2. BBNEF#T PROVl81ONS 

pATE QE DIAC~ 1$ 

!f, aher tlw wanng pcnod and whdo t►es por;—,y r3 m 

fatco. rou or an rngured dapendent aro ffrst 

dra{)nosod ao hrmhg canee3r. wo rvrd pay tb?twtits 

a;r provdeo bobw, If tho diupn®sia u mada wh:o 

rtos;,tial coalrner7. we trdl Cay o£nattis rotto3chvT3 

1a ilre rrr5t d.ay ol conhnomunt. tf hoLpttal 

ccathnement rs basea cn a craVe,tt>t+al d:atan4s,q. 

wo wsn pay bnntahtr ratroactsvo to lA;r dato ol ti,o 

provrsronot diognastS wnon an(i rt a pasrtrvo 

MdgnPB+x IS rrtade, tn naa1716r Cc75® 'oytfl tetrG'MChyi? 

borwh.s be patd lot any porrqd: 

• irl or,tx3s ol 30 days; or 

e pn,p to t.9A end ot thn rrartng penod. 

It you ctt a.n rnsurod doportdent aro tirct diagnosod 

as hevinc} r,enter dtsrng tlue wattr►g phnod, Ixtnohts 

wd1 not tw payaWo until two yoZra ol carltinuous 

covarer,o aftor th$ date at drs)nobrt:. Benotits wd1 

bo tssyrb,'a lcr &ny toss coramonang or se~virsls 

rondernri thorea.'tar as prortded bolow tt lho 

CavYaraga rllf7f:xin5 In forCe. 

t'ayrnont of bortefns is subjoo•.t to ata lian,tations. 

esctu4rons, cond4ions artd provlsions ot thes pObCy. 

DE>:tNtTIONg 

"Dato ot Dlagnosfs" means stw date th>3 bssuo 

;,qr.~Crm~n(91. curtwafs) and 916 t;sar(9) ig(ato) tJtF}r1 

uport whitA tM dutgno;is oi cancer i5 !z3 +;d, 

"1Vaft►n(] Porfod" rnearig n poriod ot tune 

rnms,duttohtr I„tlawrng the date rou er an sn2urod 

denaatdar.t ts firsl coveced undor t3rrs pobty liotttpo 

bocaming olqibsa 6or fu91 borwttts. P:o troreOls str0 

be pa:J lor cancer Irtttt dfagnase4 durint) tho 

warhntJ perrod excellt fer 1p55e9 ttlCurtnd oi 

troalmttnl rocc3vnd at 1oa61 two jroara attor Iruo dste 

o! d4sgrios+s. Ttt,e w0lnrtg pEri,ott is shown tul Par}o 

3. 

"Cancot" rr.eans a tfsoaso. in:uaing HodOkin's 

DlsoASn And IOukt:tma. whttXt is mantfesiod by tho 

ptattence af a maltt}ntvuy c.'saracterixod by ttm 

aDrxvenal vut unwntrWlod groaRh and SproOd ot 

tnilVnan1 cetf9 anC inVajlon of normal ti55Uo. 

Cnncor is turther deftned to inctudo cancor 

caM{nntt tCn fnu site ot orsgin wil'hovt .havinp rnvsdvd 

ruugHhAnnp tissuo. Protru-drgnetnt conditions ot 

canaicmt, wi<h rnfllrgrlant polerlua! 3ro nol dovmad 

to bo carux,r ur.dAr th,e pd6ey. Cancot ma t ho 

posit-vely diagrosod tty a phy:ivon upon the 

mtc+roscopic exttmtnaaon ot ftxt>tl liasue or 

pmparstrons frC+n 1'ro tir,me ay^,tam da,thar d::ruig 

Irtg or ppyt•monem). ,Tho dtaqno9era mu31 tNJ 

t>esod satc:y on tha cntorta ot ma0lbnancy ©n 

aaepted by tno Amarican 13oard ot Pathnrogy or 

M Amenzarl flsteopathtc SowK1 0l Pattloi^q}y ahor 

a study ot tuslot;ytologrc arc-hitt<.ture u panorn cf 

_..9t;atto9•88} Poge 6 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 50 of 76 PageID #: 76
rne syspect tumor, lrssua or s;wcir^.8a rt a 

ooaUivc rJraano5ls Cannot be madp, ClrntCal 

diganoSiS of carref nr8 ba deemtxd to be a Fasitrrn 

]iayUrosis orCvrdOd; 

• mo rncC.-cal ovidonce suDSlanEi9Cy GtD6umonts 

:r,e ouegrrusis Of :aiKer: and 

• tr'e inSyrOn p¢rsC+t t[Mves deltnitivp tteatmenl 

!.x can,er. 

-Phyniclan' moans a I:censad practfionar ot tho 

neavnta ans acting wIrJt n tho stxoo of twcn licence, 

• anys:ciar' doaS not irctujo you, your spcuse, 

,aaranls. cMl..rgn- ssnllnqs at cotr8sponding +nQw s. 

~Hospltal" trwan, an in,titutidn kcen,Cd 1s sucn 

anJ operating with,fl Uas sccAa o1. 6uGf IiCenso, 

'wospnel- dcos nct tnclu>io an instaution or tnat 

aart of an mstttuaon opeta><np primercy aa a: 

• conva escrnt, rost 'or nurs,aig hcme: 

• n:iRb9 for :he alJed,.dNg aQfl;C1s or alcQh7!icS; 

• rcreillty p,;imtts-ly sftarC rul. custodr.tl, xtucat{ohel 

or reha,ilflAtry'e C,ero ot SQfVICQS. 

Tne team •twspaol' mc udns an Am.rtotory (ouooauerU Surt,pca! Canter. 

-Hospltat Gontinemont or Corttinod !n a 

Hospital" tnaans, you Or an insurmd ttepclirldont 15 a 

tgg,s:erea tred~ausnt overnrght In a hosatlaf upon 

ttti• recammuxtatuon nf a pnysicetn bacaus® ot: 

• 3urgery; 

• emnr,t•ency cabro: tx 

. resrs ordervd by a ptroivaan as a pla.n.ned 

l:rrt-Nminary to irrRp.ttYnst admission to a hOspnal 

witnin 4 days. 

For sro purpose of d;tanevnog the ttcnord ntryab:d, 

:wa 'days of camel +:on{tnottront wm bt, constdatcvJ 

onn lup ttay ot confntmaont, 

"Partlal Conftnertlont" means canlinuovs 

uearf116M: ttJt a1 leaSt 6 hf:Wts tNt n91 :tior9 lhan 12 

hour9 ur any 24 Itour penod. 

Flnende$ Caro Faeltlty" fneans a nursrr+g facihty 

licenseh ena operatl70 as such under the l3v/5 Ol 

the ju:iscfichwn wtfich il is localed whron ptOv;fes 

cont-nuous 24 hnur0 a day nursing 4Ctvr0 undOt 

tho su;.er%ns+on ot a qraavatz Rc~~totad f:urscj 

(4.N.1. 

`t{oep:ce" rnoans Jn cnstuution or pan ot en. 

!tsututi5n vrnrh: 

• I. t zerfsed tts Such: 

e is oparatoA actortling !o law; and 

e Fmvi;ies nussrnL srsrvrcA artai Hospma Ca:o Far 

tarrtrmally ul palronts under tt>a supervibon ot 

Regtstnrud Nurses al 1he diraciiun of a 

Gfi7sic~vt• 

86t+t5FiTS PAYAQ4.E 

3cnalns payat:te tor cancor tust diagnosFd wnde 

thf3 pa'.rt:y ts r,n !o--ca ar« 

A, tnitiat Uignosis Fismm!it — Wo v,n:l pay tho 

turno sum ben0lil 9hown in Ine Policy 

Schnxlulo d you u+ en inwred uoporicant are 

tirSt OW4nns'Jd as naring cat:cer lalner Ihan 

vcin eanLer) slttrr tho waitirto 1?vriad. This 

Oenfitit vWr31 tte p3ya1118 only Onee weth 

toSpoci t0 ts+3c.h pt?tson insured. 

®. Cumiflativo Faat Occurrence 13onefn — 'vvu 

yrdl pay 3 lu-np 5t:m banotil oqual to tAQ 

amaunt Shown rn'tcie pohcy ScdsWule i42r 

carn tuu matun covorag-a has b,:on in force 

ettar tha yvadinq oCrsod d yau or an tnsured 

deptrnGont aro :rrst dtagnosad ds having 

cancer (olhtx thr,n skin cancor) a11or tho 

waal:ng pctnod. Tns bonattt wdl 3ccumulata 

trarn Ino tind of Ine warhng penoQ unttl tho 

sconar of: 

o tha ddl0.ot didtJrie3ts; nr 

o r.io tlalar you or tne inst.re,,i deoe:xlent 

attasns ago &S. 

H canCor rs tirsl dtapnus,ad alter aaeaTmor.t 

of age 65. 'he benetit accrur%g al ago 65 wdl 

bH pa:9. 'ftus ben$lit ur.11 be paVablg nrtly 

once wrUl rospOcl to eaC3t parson ursurod, 

2.2•goo t taS-fiR1 Pa.3o 7 ICN 23-0011-42 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 51 of 76 PageID #: 77
Of 0 6 

c 

u_ 

Mospnat Conlrnum3nt 8onein - Wo wdt 

pay ehe t>anetd sesowre tci tt:-0 Poh.^y S,~iiaduto 

tor oach day nf any continuous hosprtal 

coniinemrmt meWcatly nacossary fur thu 

trcatmont o1 cancer. 

Positiv9 Diagnostie To6t t3onotn - 11 

lati•Gr810r}t losis, irxlllr)iM X-rays, r8sutl tn a 

pOLITWf d13SjnOStS ol WnCni.(n1110f tt10n.Skin 

canCef) 'Ne witl pay ttM acntiil co91s mzunnct 

Inr Str:h t4Sts ot tdays, sUblect t0 tnEr 

litotimo maximurtt shown +n tho Paticy 

Schodu:o. Tha diagradis mvst txl mflo 

vwrt>tin go tlay, td suDh test5 Or r-teyS. 

Surgrcet 8onotit - Whon a surqical 

tY,lUralt.?rl iG pftrlorrtl6d h}' tt1D UEiNInOGt Ol 

and tollowing a tliagnocis of c..rlcor, wo wr!t 

pay the leo tor such oporacor+. inctucing 

post aporanvo ottn:sdanca, a:rts;act to tho 

maximum statod m tno Sutgica.' SchoCvte. tf 

two or moro surgi_sl procoduros aro 

porfoaned ttureng tho courso of a.tnqlo 

operatAn, wa vrdt pay ihr3 bottobi for thc+ 

mtJrn costSy prcooduro partarmnd. 

RrosMiplion Drugs a>nd tAedir.intis 13tmwiht - 

Sut>coct to the maxirnum shotrn in tho Policy 

Scsllxlulo, wo win pacy tna actual ctwtqos 

Jor pioscrrpteon drugs antt modicinos 

ittlrNn:Sta►ad 10 you or an in9runll dopondGnt 

lor itlo treatment of cancor whdr., canfintio tn 

a tiospitaL Such druc» mM modic,n" musl 

Da epproved by the Uni;®d States Food end 

brvp MmrmstratUcn (pOA). 

faaUiatroal, Chomothoropy and 

ImsnunGlflP`apy BOnbfht - SubjoCl to thA 

litalirno rmaximum shawn in ttto Policy 

SchoduRe, hio wip pay trto actuat ynsts 

rnctMod 0 you or an in3urutl depundorit 

rr_ :o?vo tor [ho lruatnx nt at mncer 

a to!.aractic,thsrrapy ussng etthor naturat or 

afihcfatty propagdtod radcaooa: 

rnter9tival or intraci5vrty appllCBhon ol 

tLidrum or rat:torsotopos in 58aiod or 

non-Sakit;rd .P,Gur=S; Or 

• canc4nCr0ai fCytOtOxrti ChornrCal 

sutrstanses 10 Jnctudo IMt atlmm ;irjJtQn 

..tharo,7t, 

2: •3W1tOcJ-89i Paao B 

Such trCatment mu5l be a orocedure 

appreve•9 by the FDA 

H. At7onmng Physrcran Burltaht - Nfe witt oay 

dw actual eowv ineutrod, subjoct to the 

r 4tzi~nurlt shcrwn m Inn Poticy Scheduls. 

oach d-hy you or an rnauroG dt>aondent, wfiite 

hosptt8l c3tUraoc7, repuuo tt:9 semces of a.nd 

are viSa@C by a phy9rmn oth.ilr Marr tne 

surge4n who po-rltxrnod surgery. The term 

Vlsit rr:narl'a litl ac14V3t par$Or181 c3`I by ttle 

phy-1,16an. 

NutSH4ij SGM/Co3 BBnBfBI - Wo K'iL pc;y It"e 

r7ctu[il 4ost9 1nC¢rred, SubJBct to t110 

rrtarcmtum stown in tho Po`icy Schoduto, 

oaCt1 dalr ytnl cN an insurtJd duprxldwt. whitt3 

hospita) confinad, rot;uite futLtimo, 24• 

hour p•rivato caro ar,d atisidance by a 

rog:4ttund graduate. rronsod prachcal or 

trcont:twQ vocation.7l nurys. Thosg yervrcas 

tnust txj *vpk~fod ansl autllortzel by the 

anend:ng phyacran and must bo providod by 

3 person otnnt tndn you sY yUur 5voUSe, 

paronts. ch:drert, slClings or correspand--nig 

+n•1aws. Thas bsnaht is nfl1 payabte l wcll 

sarvict+s ato lurrusheDd by a nurSo ay rn,,sos 

omttt0yad by and rocetrmg cornpensation 

hutID trto h.o",p;lE1 whoro yoli tx tho lnSguUd 

tlapondtmt r8 eultint3d, 

J. Mostho.3e Beneflt - Whon a surgtcvl 

uQOrirttt)r1 iS porfaJ7nUd tnr thn ItnytmAnt Af 

arra5t o1 C'J1c8r, wa wrll pay Iho 1Ctual 

ctvuQos ol tho ano;thostotoprst, sub~ect to 

tho nlaxirrnum silown tn ina Policy ScheCute, 

K. t3lcod, Plasrna ano Ptatsrerts Bnnoht .- 

SuCjoca to thi Idotimo mlRrmum showyl rn 

rho Pal=by Srrem,to, we wul pay tho actual 

costs ol bfood, plasmo or platslets not 

danated m repla,:t:d. 

L Prostrulsis 6e,,e1l1 - We wiU pay rhn actual 

cayls incurrod, 5ut3)o:t to tttu lilohmo 

mfucimtret stroven rn ttle Pol" Schodu:tt. lor 

ollcn proathoGc dovrco proscnbod as a d-roct 

rottutt ol s:jrqery for cancot. 

N. Transpe-.tation Benafit - liY.i wrll p:ly iho 

actual costa incurred, aubjoct t0 tho 

maxrmrXtt shown tn tho PGticy S:hodutn, !ar 

eahcr (but not bolh) privato passonqsr or 

rommon carru.K callJt hitnsportation ol ycu 

or an rnscu®d dapandool to and tram itto 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 52 of 76 PageID #: 78
• ~ ~ H~! 

nnarear tac=rly 'rqupped tn Rrair7s.raqu+rsd 

treormr;nt d: 

9 the crp_atmer.t has btwn spacahr.auy 

prescrtbod by tfx attrx+rJing pny5 tian tor 

tno triga3mCnt at car.car, and 

• rrhe tactrty rs tnore ltran $p rmtes t+orn 

ttte rgsrdartco ol ttto persort re+,ca,wny 

riQp(T01t. 

We woi rYo:rBte any common c:arnor boeoht 

amount paid if you ot yCur spousu 

accornpany tha porson roquuinq trazunont. 

N. ATbulanCtt 80trg1d - If yoie rk Oq it:;urud 

ilapeadent rt3auire Iranst>Mhon tyy ac or 

greund amttvfartco lo artd trom a hosoitaf tar 

con!tnOment dfW trttctlnenl ot CncGr, vru vntl 

iany th~+ actual cc+sts tnc:rrr~. ~Ikflct ta mn 

ie:yermurto ghown in tna anl:ey Schr.cut(a. 

7'to arntttpWce servtce must be orov0ed by 

a IicQnsad g? prote5sionat SmbulSncu 

coinpany anq must h& c>ArUtiod by Ihn 

anonomg phocian as nnceasary lo protect 

me heatih ar,d safe9y of tho tnst5ed Perso-n. 

NowQrer. 11 cartcrr in n r.ewbcrn dapertctnnr 

rhrld tequi►eB ths newbotn t0 iacerve 

treatmunt Ip prOtera (tte ngwtottrn'G h3atth 

anq 4ar2ty, wa wiIt p,3y aetupt Uanspertalenn 

co5ts ta ar4 trorn Ihe riearest facafi.y statt+rd 

nno cquippnd .to troot the nowborn's 

torAMwrt. subteCt to a marsnnurr cl nct less 

t►m sl;o0:.. Thq transFortauon must hv 

certd r.~ by a Lhysrcian as nacttssary tu 

protpct the 11(`Jhh itV satnty ot thp nrfwbem 

cnad. 

~ F-Strnihy rdpnittOr lodging ®t+ttefil - 4'le wit3 

f;ay tro actuat rbst mcurrcd lor 5inglo. room 

;odgrng ot you ar your spousts, suptect to me 

maxirflurtt shoarn in tite Pohcy 5tlttadutr,. it: 

a you.(ir zn us&ertod Gapsndertt is conlinix7 

m a hvspW for tha trsatrnartt at cU.rtcot; 

. tno hnsprtot rt: the no0laol tac<nty 

r.'QUiaGSh co prUYlde tho noce88aty 

traatmont as proscrrtwd t►y a phystnan; 

• tha hosμdal is rnore thr.tt SJ mitcts IrCm 

t!re raStqtTnte qt ih9 p6rSQn rr purnng 

troatrnoRt: and 

• tne Iadgrr;g as in c:asa oroai.maY to and 

uled for the purposa ot Uo+Ao neat rho 

per40n rCGu!ring treatment. 

P. ;rtrrnctod Cdra Facdrty Benefit - Wa wrU pay 

srto acttta; ccl:t rncurreo white you or sn 

.nsured dependent is continnd +n an 

Extertdod Care p•scttity; subject to thU 

mazirnurtt shown at We Patity 5chedu!a. 

Conhncmor.t iit. tho Eatoa+dad Gtro FoaGty 

must bw ryj t8tof ttt8n 14 d8y8 folldwin{j a 

ponod ot f+osprtat continomonl toa tno 

t:aatrrrent ot catacet. ihL4 battat{t rs pnyan:e 

tor each ponaa of contrrtament in an 

Extended Cam Ftcituy to:stmng a poriod af 

hospitstl coaiinoment. 1'ho maximum 

numbor of days tho tr?n411t fe paytltNo Ohalt 

tx3 ttta nurnber ol day, af rMt irnmodeatoty 

procHd:ng taospiwl r.ontlnernont, 

a l+asp~co Catn eenpnt -- Wa w,q pay a tioneta 

1cr Oa:tt day you or an inSuroe dept*rlQent 

rucoc.ros Hu5prctt Caro as shown rn tho 

Poticy Scheouln. Surh cartt may be 

prrn+cad whikt cenfrcted in a FlrtSpic>ar C.tnter 

cr al tne IneurQd PQrsari s ncme. This 

Hosptco Carn eonnfit i^, payebte.it: 

e tno tnsitrr# Par,en has becn oteqnost.N7 

as tetminal(y iIl dUe ro cEzncor by th+3 

attandtng phys:cran: ar.tt

• Wo rviceive o wrcttvn stat©rrter.t f+om tho 

Mospice Case Facitity canttymg rhe days 

On rrreci fxo wa.^. pinYK;tdQ. 

PARi` 3. l.lh1lTATIOPtS Ah10 

ExCLtfSIOtVs ..~ 

1?as' potryo uays baitof,ts cnly as a resutt ot a 

qOfulrpvra drdgnogis ot canc8f InCIUUIng tho Muoct 

o+itrtnsicn, rnofastaac . sptoa+! ar iocurrunca and 

treatment thoreal. Tt:-is pc1RlCy dooS nat pro+dtFe 

bone►tts tn+ any othot drsaaso. s,chn65s or 

incapncity, 

tiYAT71N{3 PERtpD 

,'.b Iwlrcy contains a waiting porrr,d. Tttv waitin$ 

aoriod is shrnnn in tho Poticy Schodulct. No 

bonatns wid bo paid for cancer first diagnosed 

br+fose I'te ond o! Iha axmnnq {aertod except far 

tosSBs rncutr9d or tr©atmL•nt recer+Cd at 1411,1 two 

_t•9001(o9•a8) Pape 4 ICN 29•001 t •00 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 53 of 76 PageID #: 79
yearS atiet tht3 dala 61 diaqnas:~_ Tha tnrlial 

f.:a~losis Beno(t7 and Cr:mutativo First t?c.curfanca 

taCn6l,t wdi n41 be oard for cancar 1.*a aragnosW 

belUre tt19 ond at 1he wertinQ perqd. 

TREATMENT OR SPRviCES r-oR wtitCH No 

EXPCN3FS ARIE INCURi2ED 

wun tnu e.raeptan of r.ho trr:tiaf Drognasis &onufit 

ana tne Cumulatrvn First Ocsurrorrco &;nelit, nu 

t34nEtns vall be ponn under thrS polrcy unU3sS a•lo4ai 

aaDdrty uxrsts lar tl`ie payment of Axpenses i.zcturtid 

lor the treatmant ot 5o7wcos rondvrad. 

PART 4. PRElVElUM. RENEWABILtTi Y 

bPtD T'ERR~INY

ATiOtN PROVISf PJ5 } ---- -..~,. .,.. ._.....— -- 

GI~ ,NAAt.fYEED AENE~'VE9LF 

Attar Ina arinal pretnrum ts pald, yott may eonnnua 

tnm, pot,ey :n torc4t by ttse ttrr.t+ly pitymanl o'. thn 

FQnCyY01 pft.'mium9. K'e cannot plOcO any 

rvstnC!,vo rinars ar ondarsemnnts an Mo po,ticy 

anflt rt tLTS b0en ISStM, We CannOt r@fuSe t0 

ranilw thx pGity d lAe rtsnewal proftims arfi perd 

w:ion auo. 

Tna rnrtat tuortrium ts sRown an P3ge 3. it is Iso 

arnourri at Grcrrsitmt thtet m-usa bR paHJ on or bofevo 

tne Puhcy Gffnetr+o Dato. R it oasod on ti+o 

rr.ssarartce provrded under ttrs polrcy rrtchu7ing any 

artachsd ndgrs. tho pasons atsured orscI your ago 

on tnm a.ato of rssuo. 

'r.a ren©wAI priJTtr4frlS vnr- De ouf prumiurns in 

,;tmct tor rnf+ potsorls dnsureo on estts aremrum 

[}<i6 Dale baSOQ an your eQa on rhe dato ol 15sue. 

-Frnxxum Dun Da1u" mealts thu duA datra of the 

nowt >xtxrv»m tor tral pcttcy end arty attsc/:ad riders 

accosa=.na. to th® psamiu:n psyrrtent fraquensy psan 

then rn rafiect 

R~r.~tr ro cHs~kc~ PEt:ralfaM RA'rEs 

Wu may chanqa our nrontitun rates.lor 311 pciSpos 

ot tras type, tsul not m9N oh4n than OntB lvvwy 

twelvo mott,ths. If wo ehango our rntas. trio ct+afige 

wru ;tpp y to Sm pOLCi4s al thi8 typo rn ttxi statrr 

wnare ycu hve, vvo +mu g,ve you at to8st 31 rl:ays 

pnar wrtRrtn nahco rif vny Change. Wo wlu ma,t th4 

nottze to your tast known aaaross. Tho ottoatyo 

dIIIA Of II'.a chal'1f]& w,p be tho Prnmrum f}uo Dafrt. 

on ar r•ert fc9lciwtlny Ine end a1 the 31 day 

PwEk111JM PAYMEUTS 

Al1 prcmum paynae:ttS are duo and oayaDicr rn 

ilctvanct, ot tho ;toriod to wh-ch thiiy opoly. AII 

prunrums aru payalt:,3 to us at our Homa Offrca or 

tD or. avtnqn7ad atJeot in BCCarCenCo wrlh the 

qrernium pdynttant trequortr,y plJn CtpctCd. 11 you 

sa roqruss+. vm will giv® you a rocorpt for, emcch 

pay:tstt.t re-r:aivt+d, rrg-jod by ano ol our ofheersTho Fromiuma duo vrilt inc:udo the cost of 

nt., uance a:ovxteC by t1tH po'ssy areJ ttrty artached 

rutcrs. 

CHANG" 1N PAVtuEMT FWEOUENGY 

Thrt promiurn payrnanr trequancy ptan rs rno ona 

otacte>i by you in :ha apatxanon. You rnay crtan3a+ 

1110 t•OCIuen[y p18n fnr fvtUiO jt27yrn4ntS On Sny 

Prermsn tJuo Dato by PnymQ lho eppropnotc 

Femrum Imtn ctu9 !or t~o cfesaad freounnCy. 

GRACE PEraiOD 

Tt:e 'Graes P-incd' is etw perrD.1 of tltna 31ter a, 

promrum Duo Darg that we anow tw tho p, ytrwnt 

ol tho pnrmamt th.an dua+. Atkir ttttt nr,r.'t1 ptrlmkrm 

is paatl, wa tsllow a 31 day Graco Period ta tno 

parrw.-nt ut orttt subseQuont pionmrnt dae• t3untuJ 

a GiarB Pericd, the instnarrce ytrovidtsf tty Ihe 

f:alicy, ,nclutung any at:arhed r;de-rs. wu rosnwn m 

lQtce, er frte orumtttn cius is not pma fry tho end ot 

tna Graca rtirrod. ltio rnsurance, provadod wifl 

7errn7riJte. 

TERbA 

tnsaranco pvonood w^tazr thts pcUcy begins at 

12:p1 A.M. Sfar*4atd Titae at etw ptaco wnara you 

resida on tno Palicy Effacaiva Dato shown ort fzaelr~ 

~, SuC'IE~t t4 ifte Gtt3C8 Pt?rtQd FtCva5Wf1 cCvW3.~0 

wa ond n t2:ta1 aht. Standird Tm,a on the next 

Or arry ,vt"quont ProtRium ©ut- Ualo unlass 

conttnuad by the .timaly paymnnl oI premrum. 

Yemunalwn s,f the pQlxy wO not act Io vtr•d or 

ruducc, a cLirm tor any fr.trlslits payablo Orior to ma 

dato ot tatmmwtiort. 

fiElFf STI4TCRIt3NT 

tt ;e promwm out: rs not Dald ana tne pohcy 

tertm,natez. you sney roque;: t'tas mH po4cy tw 

regisl8ted by sutxnitting Inx+ pttxnium ttuo to u_ at 

r.4Dt71rQ9•c~SJ pxga t0 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 54 of 76 PageID #: 80
:u: r.amo Af+t•.:e, if we iiccept Ino promrum 

sucrrutte,j wrthout roBurhng an apt lrtatwn tor 

re'nstacemet+r, ihn paiay will be doomed roin,tatad 

Or, Lne d8tr3 •r4© roCWvu tnO prJ.7mum (>3yrnfKit. 

It erp rr;,qurro an 3ttplrLatton tlut ttrl to gr+B you a 

• ecmpt for Ine or"mnim 8upmrrted, the poLc,y rrilt 

t,•N, ufmmod roin5t.ateG on the Cate we rocerve the 

rNnm.um payrneru, t=owover, rf wo reauito an 

a;.pNcahort artd y-va you a rocerpt. thP palry vall op 

aeemoc remstated on trw.t date ot toccrpt it: 

• we a^ppjna0 your dppl:"+_t'on: or 

• wa fed ta fltva you wntten notrce ol our 

drsapprovP.l within 65 C3yS atlot vre rmotvo 

yaur applicat►ort, 

tt Sre paltcy, ts roinstatod. Cto Bon!~tits pfnvE0d untl 

t:a payabra only lor lossos inctarad w rreatment 

co9un motrt trcttn t0 day9 after rnc datp of 

r4UtSlatenlent. 

in aIl o(h9t respec ts. tlte insuranCe provides wip 

remasa ttio samo. subjecl lo any bnutSlronS we m8y 

Istuco an such tnevrance as a conttitton ot 

rerns:atemnnt. N1a wtJ g'sva you wrKten notfce of 

any sucn lirn:lafrons. 

PART S. CLAfPA PROVISI4NS 

NOTIOE OF GI.A1M14 

wntten nootice of c!ainn must bo gVrtn to uS withm 

X. t1ay9 artof thar a'tM or or' .~ctirroke of 3rry tG5s 

cavure0 by the prolicy, or as soon tharoaror as is 

raasondbly floss+bte. Nobce grvon tsy yctii or esl 

.o.r oeha:f tu eur kortte Otfico rn flatlas. Tuxa9 

&,m rntormntton strticelant ro rdentity tnn per,t7n 

nswetl wdt be deemod natieo to us. 

CLAlM FORIitS 

;,o;,n reccrat ol a etotiCo of ctaim. wo sxtt send yflu 

rne rorrn5 wr+ nxlyr9 tCw filing orool pt Ipyg, tt We 

uu! to !urnish suCh tonn9 iviCun 10 d8ys Wtor wo 

rar,ewn oolice oi e ctolm.- nur proot of loss 

:e4urromontg wdl taa tttot d.v,o ern not+hed in wrrtulo 

Or tlro >r.rtvr0 dru! Urtont ot thg foss or troatmenl tor 

NmrG't benFthiS 8yo cl3wrted. This irnform8rrort mUst 

oe gr•een to us wrllun tttr3 time pehod for it'ng proof 

:I raBS. 

PRqOF OF LASS 

1Nriflgn proot ot lasb must he gi+vrr la Us df Qur 

Homo Otfhr.o witt>.in ?0 days ahEr tho dala of :ho 

Wss. Fvluro to furr:i:h us sur.tt proot x+rh:n 5'9 

eays wrii not vo~d or teduce any ci3ir,t if: 

• it w35 rtr,l ru3,Ort, tfy po:S+Btu to 00 8o: " 

• procf rs ar:en as soon as rcrasonob:y possrh;o 

thoraahAr. 

In any ovvtt. hc—*ov2ir• ptout ol foss mt,sf be 

proYidfld Us wifltin otui yatv ttt[o+ tha loss unless 

ycu tack tho tagrJ c=aty to do so. 

PAYMENT t3F 19t'cNEF1Ta 

BOrtfifcis f4r tLr+y IoF9 LmvBrod by thl5 p0licj wtlf tbe 

i,oa! uomti-dw7bly .v0on our recciCt ut sohsfactary 

wnqSon Oroo: or 1o55. All Wn.Mits wdt be pard 

ds3ectty to you d frviny. .1ny lionpltt9 romeinvg 

unpaid ;ft your noetlt will be pfii4 t0 yoau SpOvso, rf 

any: ethenm5s+ to your e6tata. 

FACILroY f)F FAYi11EFlT 

rf bonofto Ixtcama payahlo to your ostato or to 

anyons Nfia rs not la,qaa;y cnmpc+tent tn g,vR uS a 

vatid re!laoso, w® m3y pay erp lo $1.000 in bsnetits 

fo ona of your retartves fGy blood or marnagey 

wtwm wo dc>;m lo ke rnasonably ontatsQ therr,to. 

Any 5uch payment rrLide in good fath t)y us ve'ilt 

rolievo us at :2II liabiLty to thv oxtunt ol tho 

3ayrnErq, 

M60tGAL EXAPAINATIQt[rAtfT4PSY 

Wo ravn 1ne nght. at o+rr e"nse, to navo nfrycncr 

On whom 3claim ts basod be uxanuned by a 

physr_ran nt Our chace dur.ng tha f;t,Mc,rtxy Ot 3 

cta:m. We aleo have tho rrcyht, at our expenS@, 10 

tt.ave an nutopsy pt;'rdorm-d on anypne on wtxtm a 

rJaurt is bo .od. tujlvss foab~ddrin by law. 

ACTIt;7}d AT LA4Y 

tvo acl,on at taw or rn Qquity may 60 0tought to 

reCover or, tfns Gabey rintrt 60 days ar,er txopor 

ritl(torl prt?ol at 1o$:o has t>gRn 1gNnn tQ U8. tdn 

such acvon may W brpught at alt atter a petqd ot 

ttsreo years lrom thfl trmo Sutn ptoal is ra,u:n0 to 

ba furmtshad (B year9 in Kan3as: attnr tho 

,:pplicable staruta of t;muauons in Flonde). 

_2•9001t09•68) pegs I t ICN 29•001 r.OA 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 55 of 76 PageID #: 81
PART 6.. OSHER POLICY PROV'ISlOfliS 

ENTIRE GONTRACTrGHANGES 

' The cnirre cantract ot m5ur8nce cottststs af: 

^-}. .Tru- pohry farm, mctuamo arty anactt_«d r,aaxs. 

~?i+v t'•.. or-Art'SorsF'norils: nno 

r•' - • _. 

-j+ l;.your aap!icatwn, y copy of whtch Fs otstctmd. 

-°~r •Nb pete, eicept ortg ol our ezecvt,ve olfrcets, may 

• ' 7C118t1gQ, Wijive or olnEirwiBe attor any of the torm5 

a• t:arlddi0ntt of fts policv. Arnry cirange musl hu 

madb rn writrnp auld must bo sfgnod by ane ot our 

j

•• ctdcars, Na agsln: may cht►n3o. wawe or otherwtge 

aner 1ho Iotms or cotxJdeort.g af the Wicy. 

1.1ldITS ON OUR CONTESTING 

We rely on Qlfl 5latonr0n15 m3da rn the appl;Urtlon 

as a basis io tssuo 1hc policy and any astacheG 

naMs. Those statemOnts, In tP.e absG2co of hauj, 

aro nt:itmriil raproS4nt01rons and not Ofatrantros. 

NO statoment may od UseC by us as a basrs lo•1 

cnnte•.nny a clorm or voidino tho rnsurance 

provraod oy Iho oobcy unloss i1 is containad in tno 

spWication. 

FurSrtnr, wn cannpt Conte.l any Gtat6mDrtt9 mado in 

InC altGhcatron, oxceflt lratx;utont rni9s:atotnc4nts. 

ahor covaroge hag besn rr► forcn tor two years 

s woeld n0: nav6 acCOpted a p'Gr7mium tor Ihe 

msu•rante 

rn OnhQr co:re, our tab;hty rs lirrrrtoA to u relurn of 

ltte ptemiurns oard for Ino petrttW not coveroo. 

OWNERlC.HANAG QF ¢WN6ASHIA 

l;nless o:horxmso notoa on the. apalacatton, yo-i aro 

Ina owner of Ihis polity. You may transfer 

ownCrsnqy to SAmoCne otse dnyltmc whito tno 

pa4cy Es n tarcn. 

To lransinr, ownershtp. you muB1 IiIfl 7 wrrttefl 

roauosl .wHb us a1 our Komo OfFtco on a torrt 

eccaptatNo 1a Its. The trnnstfar wtls bn rttfa^tive 

trOrn Iho r{a:0 tho roquOst i3 sipnod by you. or 4jtor 

if you so indicala, upon roceipt t)y us. We wt11 not 

bo liablo tor any acaon ts1<on ty us undbr qw tomis 

ol It>iS Con6raIIt prior tn tho UJtc 'Nr rC,-xtvo thn 

stgnod requosl. 

ASSIGNMENT 

t38ttrY.dS oati'aVt3 unCdt I•'uS pOUCy rnoy tHr 855►7nod 

lo a ItutC pany, A 5 anod r,opy o1 the rnitten 

assignmertt must ba sont to us at our Horne Office, 

Tno aisiqmmont wilt tako orfnct when s.gned, 

subqcct to any rticns wo may tasto p<tor to our 

roLolPt ol ihe nC9rgnmant, W6 aSsumC no 

rostlarY.iibiAly lor Iho vL1LQrty of any a'SSrgnmCnl. 

OTHffR INSURJINCE WITH US 

MtSSTATEMENT OF AQE 

It I:1C Rq@ ot an InSlUrC¢ PL+rstNr h:ts b?frn rrus5tal@tl 

on the opEfGaetiOn. wo wilt adlust any bertoiits tttat 

uecontE- pnya171Ek. Ar:y ex=ost, pfHR'autn r9cervGS) 

Iry us vo1I be refunded, hny tuldorpayti+ont ol 

prenirum mu Lv doducted trorn the ben~+ht amounr. 

If any par,on covurcd undcr lhis F-0hcy is af5o 

mSurMJ unttCr anottter Itke poliCy wiln us. 1he 

coverago prowcea by onty. orte of tth-2 pohcirss w+fl 

L~? Itttmct+vU, Y4'o anit tolund any prem:urns paei lor 

tJuplicato covoratJo. 

CONFORRSiTY WtTt-{ 3TATE STATUTES 

Nn .n,uranr,e rs provrded any person under fhg 

ncricy whase a0e has bnen mi9stated on tha 

®policatwn. d on tho basi3 0l tho sorrocl t.ye, ao: 

■ wo::!d na1 h,ly0 providnd covor:rge untler ttw 

tloltcyl or 

If, on Ihn Eflectivo Qalo, any provisiorts of Ih=s 

pol;cy are m tonfliat .vith Iho laws of 1ho 5:ato 

whawe issuod. It ts thtomad ame.^.d[4 to con'orm ta 

flro min,mum requvcmwnts of such taws. 

' 3?-96D:109,6A1 P,Ige 12 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 56 of 76 PageID #: 82
PART 7. SURGiCAL SGHEDULE

. io dCtartnm® thn mazrcnum 3mo°.mt pSyaDte for any Lfle:atqn, mytbD(p the Surgical Va:uo lor Ifial c;lCra°Fon m 

tno Sc7tMlule Oalow Ay lntt Syr98c01 Be!na'n Factor Shc1Mn on Ptgse 3. Swgicig V:s!ues arn baSet] 0:1 tna 1976 

rewston o! tt:e Ca:jforrda /iAdw VNuo SchWu:e. 

SVAGICAL SURGICAL 

VALUE VALtJE ` 

fiBc7Oh:EN 

Parac©ntosis .. ........ $60 

Explarotory LaPpr3ltutiy . , . . . . . . . . S300 Chd.ecYstactomy . _ . . . . . . . . .. .. . S400 

BLA7DER 

Cysloscepy .................... 375 

Q•; sae Gtc my 

Partlal ........... ........ S500 Camsrbto .................. $878 TIJR Blntldrx Tutnots ............ S30Q 

aRacN 

;-zxptaratory Cran.otocny

Eurt natos Na: Fo-lowed By. , S...utpery 5175 Exclsron OI 9rin Turttor . ,. . ,. _ &1.000 

3REAST 

Noea!e 6,,opsy . . . . . . . . . . . . . . , : $75 Cuttiny hpuration &OpSy . . . . ... , $150 

Maslectonty 

Sut)piu . . . . . . . . . . . . . . . . . . . $400 AediiCN . . . . ... . . . . . . . . . . .. . $600 

umpoClOrny . , . . . . . . . . . . . . . . . S2Q0 

CERVtx 

DdC _ t ....,_ . . $100 CD!pos';apy .. ........ .. ..... $100 yacJinal Hystorect®my . . ... ... .. S125 

ALor)nfinat MyStereClomy . - . . . . _ . 4125 

Total Hysfn+ectomy WrtPt FIad'i6a! LymFbatlenectocr,y .......... S1.006 

ChtEST 

Thorac©ntests - ....... , .... . £50 (konct+osco}:y ............ . .... St75 tNed"ttnescopy . . ... . . . _ . .. . . . . S175 Thorncotofny .. . ......... ..... "0Q Pnaumonectartay . .. . . .. _. . . .. . . S750 

wattgo ResetGon . . , . . . . .. .... .. S8o0 LoCectvmy .. ................ $700 

ESQPHAGUS 

Esopt►agoscopy .......,. , . $t50 

Ressstron ot Esop6agus . . . ... , . , . 5950 Esapttaga)astrectomy ...... .. $750 

fNl'ESTtNES 

SigimoitktscoRy . ..... .... .. S75 

K]CNEY 

NflChrt+CtPmy . . . . . • • • • . . . . . . . SS 7 5 

LtVEfl 

140010 BUPsy .... . . . ......... . S75 wodga Bfopty ................ $9S0 

ne:ecwrt ot iivor . . . . . . . . . . . . . S500 

LYMP}+ATIC 

Ercision of Lyttsoh Nctls

Ax,eary NoAa OissRctar.t .. .... . . S404 ! yny"enectamy 

Uniratorar

8i.3tera' .................... SS00 

t+1QUTH 

Homiqtos,eetorny ........ ...... $200 GloSSo.tctry ... . . . , . , . $400 R[rsacfaart of Aal610 . . .. . . . . - . . . S400 Tcnai'hdutti4 Metnbqti0 .. . . .. . . . $329 

PAhCRJ1S 

Juwnosti,my ................ :590 

Pwicrcatoctomy .............. st,3C0 

VJhiDp'e Procersure .. .... St.300 

PENIS 

Arr.putalmm 

P.'ttttel . . . . . . , . ,. $ t 50 

Cornp;etn . . . . . . . . . . . .. . . . . 5278 

Radca.t ................. .. $375 

PROSTATE 

Cystnscopy ...... ............. $76 TUR Prosteto . . . . .. . ... . .. . . :300 R.,tdiat Praytatsttomy ........... . $7$(k 

SKtN 

sao - 

SP)NE 

5328 

22-900tt0&8a) Pyg4 13 ICN l8-041 1•4S 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 57 of 76 PageID #: 83
j 

• 

_~- ~ -.. 

~ 

~ 

•SURGICAL gURC31GA1. 

VlU.UE _y A1.UEaTOMACH THROA'e 

Gastroscolry . . . _ . . . . . . . ..... . . 5150 Csryr>Qoseapy .... ... ..., ..... S2dd 

?amaf Gastreciomy . . , . ......., SS9(t lsryrtpeetomy 

Gestroc3arny . . , . . .... . <...., .. SR25 WntoW Macx niseGn01! .....:... S600 

GestroY:,;unosiomd . . _ _. ........ S :UO Wttt hock Disaction .,.. . 81.300 

Practo.i^ymofdoscopy , . . ... . ,.. . . ;. . S7a '+rec.heo_tomy . . .. . . .. .....; ~ ~ 9200 

CoFarwSca;ty . . ......... . S150 

520C THYR010 

Ilil9s16my . . . . . . . . - ... . . . . . . . S200 Thyrc'dQu6my 

Corectomy . 

. .... . , . ... . .. C;~C Pardal (Ono LnirA) . . . . . . . . . . 5325 

Rrl:flCvon r31 SniNl ........ Tok11 (80i9t t.ODoS) . . . . . . .. . $¢25 

7hyradc:.ctomy VVAh P4ftW Neak 

TeSi'15 DiasocnCrt . . .... . . . . _ . . . . $925 

Radicz, Orctucictomy . .. .. .. . .. . sM 

wwa ' 

Vutv8G0IAy 

?ertia! ............ .. $275 

RadlcaJ .................. SgU[F 

li ary operAiwra !or tha SreAttnptn pl ;; tf ptlAprnMd other tttaq qtOW N91Bd, wa aHp pa}+ an arrtouni 

com;,araole to :he affount shown far Ms opitNdn mp,1 nMN snm:sr 14 iOYYnty Mkt 9ra•.ny. 

:~-300tt09-8d1 Pvge ~$ 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 58 of 76 PageID #: 84
GREAT AMERICAN RESERVE 1NSURANCE CQMPANY 

2024 Live Oah, P. Q. Box 398, tJatlas. TX e5221 

DRBAD DISEASE B,ENEFlT RIDER 

Eiel1@ilt PtoykSloll '?u6wy' rnnart.v tho Care~nr tnsu:arxe PoGCy to vt.lich 

Htis Rrdar is a aclwd artd M3s3 a nivt 0!. 

We tivi![ pay txrsretits lor oxpnnsen mzurnrcl mxt caro or 

Sreahnont rtKavod oc begun whdrr Ihia Rider is m fprce 

0: 

• you or an inst+rcd deperndnnl is Catynoyed by iy 

(}.'ty5'c7w A:~ t10vU1g Q716 Of TCrO dredd di6er15a [L 

dnhnod hoiein; 

• thu d'ugrtoai6 fa frr5t rnttno nttnr tho EKoctivo natu 

Ot tni9 f7 dar, trnC7 

• tko oxQonsos tncurfod und caro or trealment 

rendfvrxt is a resudt ot the dread d:sca5c. 

Sucti banntrts vlin hn tho sem.o ;u p,a-.0 lmy;~nttr timdar 

tha Policy as a r©5utt or catmttr Wld `ra to gppicd tU 

itnq 34rYft to nt091 thC• ben4til nie'111r11urri9 ;ta:G(1 in thr7 

Poe:ey Sehoduto, rn no c.+j3 witt thu tutnl bene'its paid 

un.Sur ttwy Ridov and ttte Po'icy eRcaeb tho srnoLt 

mrurbnurti, fur >aulr.rtt uttitrlSonl. 

'Dreatl Disnaso" mu:.na 8ny ol thn taruw=ttg: 

EfiectSve [3ate 

Yhm Ettpr:tiv8 tkuo ut thia Rxlor rs cho Etloauvo Date ot 

Ihe r'ctTy to wnich It ie attactwd ar sirown on tha 

No,iGy Inloriaudicn Paqia. (ho YJaitirig Pa:.od dolc;ed in 

th? Poficy aplAitsio Ihts Rdet. 

Tertntnation 

Ccverapn gtrovidal try this Ridor vnft t9mtinole on :he 

,R)aror ct: 

+ tho dr+t0 you rcKtuosl lo tvmirnato arrerage untter 

the HmW, or 

+ t1ro Aeto dto Potl^y IWSnlnatp9. 

ExcS,l as n;heredso prov;'od above, hono!itc w1•otNo 

undfa Inls Aldur orn 6uv;nr.t to tna t9rms anc 

prwisons o1 tho Policy ta wi4ich it rs anar.nod. 

Atloixtrt'S Or,uaSat Ruyo<s' Syndmnie 

Arrryotophr tstorat Rhow-rtatic Fmror 

scIrrosis P.ccky IGounarn 

BubCn:C FWcuo Stx1t®tl Futiwr 

Cystic Flbrosta 8talsot Fevot 

Oip!stheru Cfi9 

LncoO"hs Ilnomia 

6pitnpsy SmalTgo■ 

H3n5en'S De9fAa5•9 

ILJIUS Erylsamatnsus Di9e35a 

T$y-SdChS

M-nrngms Tetenus 

Mttll:plo Sclerosis Tmcic EpLnr.rmal ' 

lt.us:.uWr oyrafoPhy tvecrulyyls S r.rr! ory d 

sAyasthe,r;a Gruv;s Tuavculms 

Ni4.mrui-Fick t}fsaase Ttr<a+emia 

osoomyetifis Typleid Fever. 

Pollomyo6tis Unik.!Bnt foycr 

,Rat:.e5 whipp;o's Disease 

22•6t2.5t0A•B81 II;+V 28•1252-go 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 59 of 76 PageID #: 85
! ~ ~ '• ~ 

~ - GREAT At'r+iERfCAN RESERVE INSl1RANCE C011APANY 

~ 2020 :,ive Oak; P. O. Box.388, Dallas, Tx 75221 

tTtTENSIVE CARE BENEFIT RIDER 

8enelNt Provislon 

YYd w'ru pay a COnCftt lor 0aG9 day y0u ot aft inSurt}d 

deaett,79ni r8 C3nhnut7usty L'Ontined in an IntensiVe Glt@ 

unn rICUI for medrealiy necas" treatmont ol an 

aCGrQenl.11 Iniury ot SiCkno9a, 5ut7joC1 18 a rramnuirl Gr 

30 aays tor each penod ot cwnti:+emem. Coatmement 

musi commenc8 whde thi9 Rider is in force. Ihe 

boneln amount is erected hy you art0 is shtiwn in the 

^roftiy Scnedule. We w1li atso pay the actua7 ctrst ot 

amoutance transpvrtelian of the tnsurod Pereort ta an4 

, trom thB hDSt%1al whQto c9nUneO providod; 

i s ;no arnbulancQ SorVrC9 iS lrrovKSotl try a ftcanued or 

crorazsronal amDtdancu com=y: nnd 

• gcrcn transGcxtatton is Certrht;d Cy thn attending 

phySK+an as neca6sary to tNotOct tha Iteatth and 

satoty ot rhe tnstued Person. 

~ 

DetinEtlons 

'Carum,;tt- mQrinq t:atn ptsd ttCotment rn Dn insensivs 

carr- urt,r ror a! rnast 12 '+txrr9 to- inclurla nn ovr>rnrghr 

stay Two or mare separate petrods ol 1CU 

conhnument ror .thp sarne Wus9 or causas v.•iM be 

ConsraorQo lo 0o Ono contUtuCus Ltertod af eonf+nemUn) 

it SnGnraitQQ oy lnNs tn8n 30 lfay8. 

-mtenstvo Can tlnrt' means an assa or unit ot a 

nosottar wntr,n at tne tulle of admisseoq ts separate ana 

apQrt rrarn Ihe Sur^yrcal reCovery raairt 8t1d Irom oL'Ier 

ger.erat seivrce rooms. UBds and wards. 6n adilroan. io 

t:e .:onsiacrred an tntensrvo Cdro Un_ it. gu:.h lactlrty 

Ty~St 

• prpwae cCn,tt:nl. 2s.)tour nursirtg anendanca by 

~j?gi,tored yurses asagnod on an eaclussvo. fu:1. 

~ umo Qass,; 

• z= unaer tne direcsron and or supervision Of a tua. 

lima physlcrart or a standin9 'tntan,rVo CarOcomminao nt tne meMcat staff; an0 

~ 

• contai't spasia` apparalLs useC m tne treaGment of 

Ihe crnicaL'y dl. 

An ICU irxltrlos icttensne cardias or corcnary units and 

:feo 't3td1 interlsiYe et'-rtt tmtt5. Flot rnc3uded In the 

dotinroon a1 an 1CU are: 

• Frograssi,m case un;ls; 

• Suh-$+.ute inleflsiYe Cae unn5; 

• ir.torrnediatn csre units; 

• pnvate monaoaed rooms: 

• oRservat c-n unns; 

• stop•e7nwn urGts, ct 

• Sny otn2r tessar Cxo unll5. 

'PotiLyr' means th@ Cancer Tr2atmant tnsurancA. 

Pqliry to which th,s Ftider is attached and ma0e ;, part 

at. 

Excluslons and lJmttadons 

No baneins are payati!a unaer thrs ilitior tcr vty iCU 

con6noment cavvod by ttr rnstrl.lrtg :ram: 

• atconntism or cruQ adC,cnon; 

• mtoYiCatiOn or ,oieg und@t tae InlluoncQ of Cruas 

r.at FresctibQO or tecomcr.ondo0 Dy Q Phy!;,c:a1n: 

• ln ottompturi :Ap4dO ur rntenuonai Scll-tn111cted 

,nlury: 

• ff+e cotamisston ot a fetony cr aiterript aP.nie.of: cr 

• any contutement 4r madiG'tt l+oalrleni far wnrcM 

you ar tthe ir7sur04 dopendont is not logat!y 

9GItg.ltet) to pSy or far wnrc:l no cllarge wtwkt haYe 

been mado in Ihe ab6ence ot tno .nsuronce 

provrded Dy tttis Rider, 

?2•0 :?ocG9•891 IC4 26• t 261-Qp 

I 

~ 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 60 of 76 PageID #: 86
EHective Dflte 

The edecttvo l3ato ot jtus Ridsr is me Efioetive Uate ot 

th5 Pai,cy io wthiCh Q 15 attactt9d 35 Stta'Nn osl thoPot,cy tnforntation Page. The Vla;tatg Penotl datined in 

tne ?o:,Cy aOies to this Rider. 

Fieinstat®ment 

u tnts FUtter ts rem5tateC pttrSuAnl lo tRC ptoviSiptis ot 

tn® POucy ,o wtwCh it b5 atidthed. DatolrlS wrlt bq 

Paya0l6 roC 

• a_CrCNnt01 tnjuttOs U<Y_uirinq on ot aIter rh8 day 

a110f ttlo Uo of reitu''tateTl9nt; Znd 

• tOsios inCtlrre6 Or eaOMOfnl.Ntt bef'j un tLr S'CkneSs 

mote m9n 10 d[tyS rtter ttu] tlaj® ot relnstatenent, 

~ 

Termination 

Cavorage provtdfd by this Rtder vnA.termse.o on the 

soonol ol: 

• Ihd date ycu toquost to terminate covorage under 

Ihe Aeer; 

• th+J d.lto the Polit;y 1qrStinl:tos: ot 

• wnh rospect to oath tnsUred Petsor. under the 

Policy, upon aitznmQnt o! ago 70. 

Extapt ae otherwtse provided citlavts, benoti:s Payabl© 

under Ihls Redor are 9ubject to Ihe torms ar.d 

provir.ionr ot thA Wolity to whir,a it is attached, 

5ocretary 

~ 

# ' 

! 

7?•o°:•4rOS631 

~ 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 61 of 76 PageID #: 87
GiSeAT;ir1[AIC>t!t n~CEAVE tHSUR~idCE C~PAkY 

tne Cd P C~x :el. CaLcs. ou~~j ?Ix11 APPLICATtO ~:~ 

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Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 62 of 76 PageID #: 88
EXHIBIT 2 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 63 of 76 PageID #: 89
:iefferson National lw.ife Instiranc;e GQmpan.y 

1'C) Bca~c 2024 

Canmel IN 4G0$2-2024 

(~00) 525-7662 

.lune 1, 2022 

Debra Vca1e 

PO Box 1043 

Van Alyst.yne, TX'75495 

Aatient,Namc: I-iugh Vea1e 

Fnlicy 'Nunilaer: O l A 109.6.8,d0 

Claim Ntunber: I3-G78570-01 

Dear Ilugh. Wr;ale: 

We ltave received and reviewed thc ch-dm ior ihe above referenced policy. 

In orcler to consider benelxts-sve need a copy o1'the Niedicare Explanation ofI3eneiits/other 

insti,rahcc Exlalariatisan-of.Eene1"i₹s showirig tlae acttiai incu.rred expensus (amount l+eft aftes- t11e 

other itasurancc paid) for thc:2-3-22 diagnosiic lali expensc and t12c: 3-11-22 to 4-29-22 

c:hemotlterapy e•cpenses. 

If you liave any questions, please contae.t ns at 1-800-525-7662Monclay #hrcat.agh Friday behveert 

tlzc hoiars of 8 a.m. atid 6 p.m.1:;astcrn 'I'iine, One n1" otu• custorner secvice ropresentati.vcs wauld 

bc; plcased to assist you. 

S incerely, 

Customer Service 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 64 of 76 PageID #: 90
EXHIBIT 3 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 65 of 76 PageID #: 91
JefTcrson N~fionul IaifeSnsurance Conllaany 

P. O.13ox 2024 

Carmel, L'J 46082 

(t300) 2C4-3340 

June 9, 2022 

~ o Debra Veale 

o Po sox 1043 

" Van Alstyne, TX 75495 

Patient Name. 

Policy Number: 

Claim Nurnbero 

~" ~~ ~tw`Asv~'<m ~ 

~ ~~l~~~~ ' ~~~~,~~~",~„ 

~ 

Hugh Vea].e 

O1A1096860 

B-678570-01 

Dear Debra Veale. 

Thank you for the opportunity to serve your insurance needs. 

We have received and reviewed your request for the above 

referenced policy/contract. 

This is in response to your appeal on the above listed claim. Your 

policy states "No benefits wi11 be paid under this policy unless a 

legal liability exists for the payment of expenses incurred for 

the treatment of services rendered." So, if other insurance has 

paid your providers, there are no expensas incurred for this 

insurance policy. 

We have based our determination on a11 the information currently 

available to usA If you have other information you wauld lilce us 

to consider, please send it, in writing, to the address listed 

above. When we receive it, we will review it promptly and provide 

you with a written decision. 

If you have any questions, please contact us at (800) 525-7662 

Mo,n.day. th.rou.gh..f'ri,day between the h.ours of 8 a.m. and 6 p.m. 

Eastern Time. Qne of our customer servi.ce representatives cvould be 

pleased to assist you. 

Sincerely, 

Tim Powers 

Claim Review 

HCL0927 

TIP 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 66 of 76 PageID #: 92
EXHIBIT 4 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 67 of 76 PageID #: 93
Jefferson National Life Insurance Coinpany 

PO T3ox 2024 

Carmel IN 46082-2024 

(800) 525-7662 

July 20, 2022 

Debra Veale 

PO BOX 1043 

VAN ALSTYNE, TX 75495 

Patient Name: I-1ugh Veale 

Policy Number: O 1 A 1096860 

Dear J. Mark Mann: 

This is in response to your correspondcnce dated June 22, 2022. Our records show that the Initial 

Occurrence benefit of $750.00 was previously paid for Hugh Veale on August 12, 1997, based 

on a diaf;nosis made on Deceniber 14, 1993. The Positive Diagnosis Test benefit was a14o paid at 

tllat time. These benefits are payable orice per in5ured. 

Surgery and Anesthesia benetits for the surgical proceciure on tVlarch 4, 2022 were paid based on 

the bil.linb documentation subrnitted with your correspondence. For consideration of 

cheinotherapy benefits, we are in need of the Nledicat•e or otlacr insuratce Explanation of 

Benefits. The correspondence sent to Debra is enclosed far review. 

A duplicate policy has bcen sent to tite pol_icyholder uncier separate cover and is enclosed as well. 

lf you have itny cluestions, please contact u;; <rt 1-800-525-7662 Mondtry th.rouah Friday between 

the liotn•s of 9 a.m. and 6 p.rn. Eastei•n Tiriie. One of our customer servico r•epresentatives would 

be pleased to assist you. 

S i ncei•ely, 

Dustin `INiCCiarrrs 

Clainis Review 

Enclosures 

Cc: 

J. Ma.rk Mann 

MT2 Law Group 

201 E HOWARD ST 

HENDERSON, TX 75654 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 68 of 76 PageID #: 94
EXHIBIT 5 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 69 of 76 PageID #: 95
JIiFrM:FtSt)N NA'1'loNAl. t.(FElNSU1tANCt: CC)h=SnANY 

11825 N. Paanapl'vania Srrect 

11,0. liC)X 2012 

Carruel,lN 4E+032-2C/'12 

18i10-G24-2726 

POLICYHOLDER'S NAME AND ADDRESS 

DEBRA VEALE 

PO BOX.1043 

VAN ALSTYNE TX 75495 

INSURED'S NAME 

DEBRA VEALE 

PATiENT'S NAME 

MEMBER I.D. POLICY NO. I DATE PAID 

BENEFITS 

S~ VIO~ 

TOT,~L, CHCa. DEDUCTiBLE AMOUNT NO RE. 

PROViDER OR OR ROT ERV. P4ED 1"1'~RK CaONSEDERED PAID ~ OODE S

FROIvd TO INDEhQ. AMT. EL{4A. DlIYS OOVERED OOD _ 

UT SOUTWES 02/03 02/03/22 .09 .09 01 000 M8 91 

UT SOUTWES 03/11 04/29/22 .09 09 01 000 L8 07 

KUEv1AR MD 03/04 03/04/2,2 .09 .09 01 000 P2 04 

UHS OF TEX 04/08 04/08/22 .09 .09 01 000 20 91 

UT SOUTWES 03/25 03/25/22 .09 .09 01 000 B8 07 

UT SOUT4IES 04/15 04/15/22 .09 09 01 000 BS 07 

TOTAL AiVI®L9NT PAID THIS CLAIM 0.00 

CHECt{S iSSUED 

BESCRIPTtf3N fJF 6REMARKS 

THIS IS A SUPPLEMENTAL HEALTH POLICY AND ONLY TI-IOSE BENEFITS 

LISTED IN THE POLICY ARE PAYABLE. 

M8 - MAXIMUM BENEFITS HAVE BEEN PAID 

L$ - THIS FILE HAS BEEN CLOSED DUE TO NO RESPONSE FOR REQUESTED 

L9 - INFORMATION.RE~CEIPT OF T'HE INFORMATION WILL REOPEN THE FILE 

P2 - BENEFI.TS FOR THESE EXPENSES HAVE PREVIOUSLY BEEN CONSIDERED 

20 - THIS CHARGE IS NOT COVERED UNDER THE POLICY. 

B$ - PART OF THE DENIED AMOUNT WAS APPROVED BY MEDICARE HOWEVER 

B9 - MEDICARE PAID AT 100°6. 

ACTION TAKEN ON YOUR CLAtM IS BASED UPON THE iNFORMATION CONTAINED IN OUR RECORDS, IF YOU WOULD LiKE TO SUBMIT 

ADDITIONAL INFORMATION, PLEASE FEEL FREE TO DO SO. "REFER TO BACK FOR EXPLANATION OF BENEFIT CODES"` 

""YUDIVIDUAL COPY EXAMINER - NCO 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 70 of 76 PageID #: 96
BE(dEFIT CaDE EXPLANATI®N 

01 Room and Board 

02 ICU-CCU 

03 Misc. I.P. Expense 

04 Surgery 

05 Anesthia 

06 NACA Other Treatment, Services or Supplies Expense 

07 O.P.Therapy 

08 Doctor Visifs 

09 Spinai Manipulations 

10 O.P. Surgery. 

11 Emergency Treatrrlent 

12 O.P. X-Ray & Lab 

13 Matemity 

18 Blood 

19 Ambulance 

23 Accidentai Death 

24 A.D: (Common Carrier) 

25 D3smemberment 

27 Hospital Confinement (Indemnity) 

27A HCIP/Ambulance 

27C HCIP/Cornm. Acc. 

27D HCIP/Dep. Chf1d 

271 HCIP/1CU-CCU 

32 Medical Expense 

34 Life 

34A Group Death Benefit 

34C Dep. Life Child 

34M Dependent Life 

340 Ottier Insured Rider 

34S Dep. Life'Spouse 

35 Convalescent Hosp/ECF 

36 Misc. Out of, Hospital Med. Serv. & Supplies 

37 Prescription Drugs 

38 Private Nursing Care 

39 Prosthotic Devices & Medical Supplies 

40 Interest 

41 Day Surg. Hospital 

42 Day Surg. Doctor Charge 

43 Day Surg. Anes:, 

44 Day Surg. X-Ray & Lab 

45 Dental (tnjury Only or Tumors in Mouth 

46 Asst. Surgeon 

47 Pr'e-Admit Testing 

48 Limited O.P. Treatment 

49 O.P, Treatment (Other) 

50 Total Disability Reduced Benefit 

51 E&E Life 

55 Major Medical 

57 Semi-Private R$.B Supp. 

58 Private R&B Supp, 

59 Semi-Private R&B 

60 Private R&B 

63 IP Detox 

64 ECF - Misc. 

65 Extra Confinement 

66 O.P. Misc. Hosp. Expense A(100) 

67 I.P. Medical Benefit 

68 Annuities 

68A Annuity Deposit Fund 

69 O.P. Mse. Hosp. Expense B(50) 

72 Limited Inpatient Care 

73 Other 

75P Disability Income 

76 Limited 

78 Limited Misc. Hospital 

80 Premium Refund / Withholding 

82 i. P. Rehab. 

83 Limited Room ' Board 

84 Limited ICU 

85 Limited Arnbulance 

86 Limited Dr Visits 

87 Limited Prescriptions 

88 Limited P.O.N. 

91 Miscellaneous 

91 C Cumulative Benefit 

911 Initial Diadnosis 

92 Policy Loan 

93 Comp Settlement 

`I00 Physcal Therapy 

101 Casts, Splints, Etc. 

FOR ARIZONA RESIDENTS ONLY 

You are ontitled to appeal this decision under Arixona laws. Piease cootact our customer serJice department at 1-800-824-2726. 

_ FOR NEW HAMP.SNIRE RESI©ENTS ONLY

Ir you havo any questions regarding this detormination, or it you would iiko to appeai this dotermination, picnso contact, our customor aervice 

dapartment at 1-800-824-2726. The Now Hampshire Insuranae Clepartmont may bo contacted for assiatanco. 

FOR ILLINOfS RESIDENTS C?NLY 

"Ruie 9.19 of the Rulos and Regulations of the liiinois Departmont of Insuranco roquires that our Company advise you that ii you wish to tnka thirr 

matter up with the Illinois Dopartment of'Insuranee it maintains a•Consumor Division in Chicago at 160 North LaSaile Street, Chicago, Illinois 

60606, and in Springfiald et 320 West Washington Street, Springfield, lilinoi9 62767," 

FOR CALIFORNIA RESIDENTS ONLY 

"Subchapter 7.5 Unlair Claims Sottiemont Procticos Regulatior5s roquiros thot our Company odvise you that if you wish to taka thls mntter up with 

tho California Department of Inaurancc it maintains a Consumcr D`rvision in Los Angeles ot 300 5outh Spring Street, Los Angefes. California 90013 or 

c al I 1- 800-927 -4357." 

FOR ALL OTHER STATES 

This is to advise you that we havo a grievance process In place, You may inquire into this process by calling 1-800-824-2726. 

6640. 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 71 of 76 PageID #: 97
EXHIBIT 6 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 72 of 76 PageID #: 98
Jefferson National Life Insurance Company 

PO Box 2024 

Carmel IN 46082-2024 

(800) 525-7662 

September 21, 2022 

Debra Vea1e 

PO Box 1043 

Van Alstyne TX 75495 

Patient Name: Hugh Veale 

Policy Number: O1A1096860 

Claim Number: B-678723-01 

Dear Debra Veale: 

Wd have received and reviewed the claiun for the above referenced policy. 

ln order to further consider benefits we need a copy of the 7-6-22 pathology report and operative 

report, form UB-04 for tlie 7-11-22 to 7-20-22 and 7-25-22 to 7-29-22 hospital stays, and form 

CMSi1500/bill with doctor name and diagnosis code(s) for the 7-11-22 to 7-14-22, 7-18-22, and 

7-25-22 to 7-2(:22 inpatient attending physician visits. We also need the other insurance or 

Medicare explanation of benefits showing the actual incurred expense remaining after the other 

insurance or Medicare has considered the expenses for these attending physician visits. 

If you have any questions, please contact us at 1-800-525-7662 Monday through Friday betureen 

tlie hours of 8 a.m. and 6 p.m. Eastern Time. One of our customer service representatives would 

be pleased to assist you. 

Sincerely, 

Customer Service 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 73 of 76 PageID #: 99
EXHIBIT 7 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 74 of 76 PageID #: 100
JEPFF.ItSC)N NATtC)1VAL L[FE [3VSU]tANCIi COA9PANY 

1 16'25 N. I'enasylvaain Str¢ot 

P.O. RC.1X 2012 

C'.nrCztc9. CN 4COS2•2tl]2 

1 £i(?Cl-f32d-272ti 

POLICYHOLDER'S NAME AND ADDRESS 

DE6RA VEALE 

Po BOx 1043 

VAN ALSTYNE TX °T5495. 

,. ,. 

' )6•T~F~,RS'{~~r~'~rFQ~'~11 . 

(NSURED'S NAME 

DEBRA VEALE 

PATIENT'S NAME 

HUCH VEALE 

:F-lrEtvv*z 

MEhbBER I.D. POLICY NC7. ~ DA"t"E PAIC} 

f` Anlr—f` 1n/°J` 

AAII1t-lii~~•-a 

SERVICG OTAL CH . DEDUCTISLa AM7UNT N0 ?L RE- 9E1dEFiTS 

PROVfDER CYR OF1 htt?T ERV, P~11D ~AA3IK C~ISIDEFtED PA~ CC7DE Ei~tD4,9 TO INDEtv9. A~,9T, t~LiA9. DAYS CflVEl~ED COt3E 

MANSOUR MD 07/06 07/06/22 .09 .09 01 040 LS 05 

CLEMEnITS U 07/11 07/20/22 .09 .Ot3 OrJ 000 L6 O1 

CLEMENTS U 07/26 07/29/22 .0+3 .09 09 OOfd L6 01 

CLEMENTS U 07/11 07/14/?.2 .09 .09 04 000 LS 013 

CLEMENTS U 07/18 07/18/22 .09 .O"9 01 000 LB 08 

CLEPREAfTS U 07/25 07/26/22 ,09 .09 02 000 LS 05 

TO'fAL AM0UN"t' PAID THIS CLAiM 0.00 

~ 

DESCRIPTION OF REMARKS

L8 - TI-IIS FILE HAS DEEN CLOSED DUE TO NO RESPONSE FOR REQUESTED 

L9 - INFORMATION.RECEIPT OF THE INFORNqATION WILL REOPEN THE FILE 

ACTION TAKEN ON YOUR CLAINI IS BASED UPON Ti-1E INFORMATlON CONTAINED iN OUR RECORDS, If- YOU WOULD LIKE TO SUBiV111 

ADDfT10NAL 1NFORMATiON, PLEASE FEEL FREE TO DO S0. "REFER TO BACK FOR EXPLANATION OF BENEFIT CODES" 

""YUDIVIDUAL COPY EXAMINER - NCC 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 75 of 76 PageID #: 101
01 Roorn and Boartl '~ 44 Day Surg. X-Ray & L'ab 

02 ICU-CCU 45 Dentai (injury Only or Tumors in Mouth 

03 Misc. I.P. Expr3nse 46 Asst. Surgeon 

04 Surgery 47 Pre-Admit Tosting, 

05 Anesthia 48 Limited O.P. Treatment 

06 NACA Other Treatment, S®rvices or Supplies Expense 49 O.P. Treatment (Other) 

07 O.P. Therapy 50 Total Disability Reducdd~ Benefit 

Vtsits 

.. r. .... ... 

_61 E&E Lifa 

_09 Sp naf Marnpr~if` ations• ~ ~ ~ ~ 55 

•n M - --, _ Major Niddical

10 O.P. Surgery ; 57 Semi-Private R&B SLipp. , 

11 Emergency Treatment 58. Private R&B Supp. 

12 O.P. X-Ray & Lab 59 Semi-Private R&B 

13 Maternity 60 Private R&B 

18 B1ood 63 IP Detox 

19 Ambulance '64. ECF - Misc. ' 

23 Accidentai .Death 65 Extra Confinement 

24 A.D. (Comrnon Carrier) 66 O.P. Misc. Hosp. Expenss A(100) 

25 Dismemberment 67 I.P. Medical Benetit 

27 Hospital .Confinement (Indemnity) 68• Annuifies 

27A HCIPIAmbutance, 68A Annuity Deposit Fund 

27C HCIP1Comm. Acc, 69 O.P. lise. Hosp, Expense 'B (50) 

27D HCIPJDep. Child 72 Limited Inpatient Care 

271 HCIPtICU-CCU 73 Other 

32 Medical Expense 75P Disability income 

34 Life 76 Limited 

34A Group Death.Benefit 78 Limited Misc. Hospital 

34C Dep. Life Chitd 80 PremEum Refund i Withholding 

34M Deperident Lite 82 1. P. Rehab.. 

340 Oth®r insured Rid®r 83 Limited Room ' Board 

348 Dep. Life Spouse ~ 84 ' Limited iCU 

35 Cnnvalesc®rtt tiosp7ECF 85 -. ...m „.. Linnite~d Ar~liulance ' 

36 Misc. Out of Hospital fVled. Serv. & Supplies 86 Limited Dr-Visits 

37 Pr®scription Drugs 87 Limited Prescriptions 

38 Private Nursing Care 88 Limited P.O.N. 

39 Prosthetic Devices & Medical Supplies 91 Misce[laneous 

40 {nterest '91 C Cumulative Benefit 

41 Day Surg. Hospita! 911 Initial Diagnosis 

42 Day Surg. Doctor Charc3e 92 Policy Loah 

43 Day Surg. Anes. '93 Comp Settlement 

100 Physca! Therapy 

;101 Casts, Splints, Etc. 

FOR ARIZONA RESlDENTS ONLY 

Yau ctre entitled to appaal thi's decision under Arizonm laws, Pleaso contact our customer servico department at 1-800-824-2726. 

FOR NEVtf HAMPSMIRE RESiDENTS O1tkLY 

ir you have any questions rogmrding this dotormination, or iI you would like to appeal this dctermination, ptamso contoof: our cuatomor ttorvica 

depnrtmont at 1-800-824-2726. Tho Now Hampshiro Ine;urancQ Dopartment may be contacted tor assistance. 

FOR ILLIPNOIS RESIDENTS ONLY 

"Ruto 9.19 of tha Rulos and Regulations of tho Illincis`Departmont of insuranco roquiros that our Company adviso you that if ybu wish to tnke thim 

matter up with the Illinois Dopartnient oi Insurance tt maintains a Consumer Di.vision in Chicago at 160 North taSallo Strecat, Chicago, Iilinois 

60606. and in'Springtield cat, 320 Wcst.Washingion 5ttoot, Springfieitl, li,linois 62767." 

FOR° CALIFORNtA RESIDENTS ONLY 

"Subahaptor 7.5 ;Unfair Claims Sottlement Practices poguiations requirtte that our Company adviso you thnt it you wish to tako this mattor up with 

tho California Dcpartmont of Insurance it maintnina a Consumr Division in Los Angelos at 300 South Spring Street, Los Angeies, California 90013 or 

call 1-800-927-4387." 

FOR.ALL OTHER STATES 

This Is to adviuo you thst we have a grievanca proeoss• i.rt placo. You may inquiro into this procass by Ctslling 1-800-824-2726. 

6640 

Case 4:23-cv-00492 Document 1-3 Filed 05/26/23 Page 76 of 76 PageID #: 102