HomeMy WebLinkAboutContract 5329�,i � '� ::�r�RETI�i�Y
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Dallas, Texas
(herein called the Insurer) �,
has issued this
' EXPERIENCE RATED RENEWABLE TERM GROUP LIFE INSURANCE POLICY
NO. 21090 , to
21091 CITY OF FORT WORTH
Fort Worth, Texas
(herein called the Employer)
As of July 1, 1965 (herein called the policy date)
and thereby agrees to pay a sum of money as stipulated hereinafter
upon the death of any employee insured hereunder to the beneficiary entitled thereto, all in accord-
ance with the conditions and provisions hereof, including those set out on the following pages which
are a part of this policy as fuJly as if recited over the signatures hereto affixed.
This policy is issued for a term of one year beginning on the policy date, in consideration of the
application therefor made by the Employer and of the timely payment of premiums as provided
for herein. It is terminable and renewable at the times, upon the conditions, and in the manners
hereinafter specified. It does not share in the earnings of the Insurer, but an annual refund based on
experience may be made as the Insurer shall determine, to be paid to the Employer in cash or applied
in reduction of future premium payments.
IN WITNESS WHEREOF, the Insurer has caused ihis policy to be executed at its Home Office in
Dallas, Texas.
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President
�;�-�n_sz�, � � �_�.t_ ) �_� ��%
Secretary � _
/ / ,
Countersigned .- ' . � �
Executive Vice-President
FORM NO. GLP-2 7515-M464
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ARTICLE I - DEFINITIONS
As used in this policy:
� A. "Employee" means a person directly employed on a full time basis in the regular
business of and compensated for services by the Employer or a former employee
� who has been retired under the Employer's established retirement plan.
B. "Actively at work," "active work," or "active service" shall mean the active
� expenditure of time and energy in the service of the employer, provided, however,
that an employee shall be deemed to be actively at work on each day of a regular
p paid vacation, or on a regular non-working day, on which he is not disabled pro-
vided he was actively at work on the last preceding working day.
C. "Policy anniversary" means the month and day of any subsequent year corresponding
to the policy date.
D. "Insurance month" means any period commencing on the day of any month correspond-
� ing to the day in the policy date and continuing until the corresponding day in the
next succeeding month.
: L --- - - -- --- - —,
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ARTICLE II - EMPLOYEES ELIGIBLE
The following employees are eligible for insurance under this policy:
A. Any employee who on the policy date shall have been continuously employed by the employer for the per-
�
iod of time specified in the application.
B. Any employee not eligible on the policy date but who subsequently to that date, shall have been continu-
[ ously employed by the employer for the period of time specified in the application.
C. Any employee heretofore insured under this policy, whose insurance terminated because of termination of
employment or for any reason other than failure to make any contribution required hereunder shall be eli-
, gible on the day he resumes active service, provided he resumes active service within twelve months after
the date of the termination of insurance.
�.- - - _-_ _ ���� - _
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7502-1260
ARTICLE III � EFFECTIVE DATES OF INSURANCE
A. The insurance on each eligible employee shall be conditioned upon his making written
request therefor on a form approved by the Insurer and shall become effective in ac-
cordance with the following eonditions:
1. For employees eligible on the policy date who make application for coverage
prior thereto, the coverage shall become effective on the policy date.
2. For employees becoming eligible subsequent to the policy date who make ap-
plication for coverage prior to the thirtieth day following the date of employ-
ment, the coverage shall become effective on the premium due date next oc-
curring after the completion of thirty days continuous employment.
3. If such written request is made after the end of the thirty-day period immediately
following the date of employment or is mad� after previous termination of insur-
ance because of failure to make, when due, any contribution required under this
policy, the employee must furnish, without expense to the Insurer, evidence of
his insurability satisfactory to it; but if such evidence is so submitted and the In-
surer determines the evidence to be satisfactory, the insurance shall become
effective on the next premium due dafie.
4�. If such written request is made by an employee who was previously insured under
this policy and who upon termination of his employment or of inembership within
an el igible class converted al I or a part of his previous insurance to an individual
policy and who again becomes an employee and such individual policy remains
in force at the time he would otherwise again become eligible for insurance under
this policy, such employee shall furnish without expense to the Insurer evidence
of his insurability satisfactory to it before insurance hereunder for the amount of
such converted insurance remaining in force, in which event insurance hereunder
of such amount shall be effective on the premium due date immediately following
the date the Insurer determines such evidence to be satisfactory to it. Any in-
surance hereunder in excess of the amount of such individual policy shall become
effective as herei nabove provided .
B. In any instance, when an employee is not actively at wor!< on the date his insurance
would otherwise become effective, the insurance shall become effective on the date
following the first day he is again actively at work.
C. Any employee who must furnish evidence of insurability to the Insurer as a condition to
becoming insured and whose service with the employer terminates without such evidence
having been given shall continue to be subject to the same requirement if he is subse-
quently re-employed .
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ARTICLE IV - PREMIUMS
� A. Continuance of the insurance hereunder shall be conditioned upon payment of premiums by the employer at
the Home Office of the Insurer in Dallas, Texas in accordance with the following provisions. The first
premium is due on the policy date; subsequent premiums are, during the continuance of this policy, pay-
( able in advance. Except as otherwise provided herein, this policy shall automatically become void if any
� premium is not paid when due and payment of any premium shall not maintain the insurance under this pol-
icy in force beyond the day immediately preceding the next premium due date.
�
Age
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
INITIAL SCHEDULE OF INDIVIDUAL PREMIUM RATES
(Monthly premium per $1,000 at attained age of insured, nearest birthday)
Amount
.16
. 17
. 17
.18
. 19
. 19
.20
.20
.21
.21
.21
.22
.22
.22
.23
.23
.24
.24
.25
.26
Age
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Amount
.39
.42
.46
.50
.54
.59
.64
.70
.76
.84
.91
1.00
1.09
1.19
1.30
1.43
1.56
1.70
1.84
2.00
Age
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
Amount
3.26
3.58
3.93
4.33
4.76
5.23
5.69
6.16
6.64
7. 15
7.70
8.31
9.00
9.77
10.63
� 35 .27 60 2.17
36 .29 61 2.35
� 37 .31 62 2.55
' 38 .33 63 2.77
39 .36 64 3.00
� B, The "Initial Schedule of Individual Premium Rates" as set out herein shall be the basis of computing the
amount of premiums payable under this policy, subiect to the condition that the Insurer may, on any policy
anniversary, change the premium rate basis upon which the amounts of further premiums, including the one
I then due, shall be computed.
LC. On the policy date and on each policy anniversary, an average monthly premium rate will be determined
� by applying the individual premium rates to the amounts of insurance in force at the respective attained
----�- .�_-_ r ..� . _ _ ___ __ _ � _ _ --- -- - -
7504-M263
ARTICLE V- AMOUNT OF INSURANCE
A. The amount of insurance on each employee shall be determined in accordance with
the following:
9
SCHEDULE OF INSURANCE
F
Class of Employees Amount of Insurance
Class A Employees earning less than $3,000 per year $1,000.00
S
Class B Employees earning at least $3,000 but less than $6,000
per year
Class C Employees earning $6,000 or more per year
Class D Retirees earning less than $3,000 per year immediately
prior to retirement
Class E
Class F
Retirees earning at least $3,000 but less than $6,000
per year immediately prior to retirement
Retirees earning $6,000 or more per year immediately
prior to retirement
$3,000.00
$5,000.00
$1,000.00
$2,000.00
$3,000.00
B. Any change in the amount of insurance on an employee due to a change in class shall
become effective automatically on the next premium due date occurring at least
twenty (20) days after notification to the Insurer of such change in salary; except if
any employee is not actively at work on the day the amount of his insurance would
otherwise be increased, such increase shall not become effective until the day next
following such employee's return to work.
C. Should insurance on any �mployee be continued during his disability, approved I�ave
of absence or temporary lay off, the amount of his insurance shall be that for which he
l was insured on the day he was last actively at work.
+ D. If a reduction in insurance is provided by the Schedule of Insurance on a specified date
I or age or other specified time, such reduction shall become effective as provided by
� such schedule.
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ARTICLE VI - PAYMENT OF BENEFITS
A, Immediately upon receipt of due proof of the death, while insured hereunder, of any employee the Insurer
will pay the amount of insurance then in force on the life of that employee to the designated beneficiary,
subject to the further provision of this Article. The Insurer shall not be required to recognize a beneficiary
designation unless furnished to it on its form provided for that purpose, or otherwise expressly accepted by
it. If two or more beneficiaries are designated and if the employee has not specifically provided other-
wise, payment will be made equally to such beneficiaries or to the survivors or survivor of them.
B, Any employee while insured hereunder may from time to time, change his designation of beneficiary by
written request fi led at the Home Office of the Insurer through the employer on a form furnished by or sat-
isfactory to the Insurer. Such change will take effect as of the date of execution of such request, whether
or not the employee be living at the time of such filing, but without prejudice to the Insurer on account of
any payments made by it before receipt of such request at its Home Office. If any designated beneficiary
predeceases the employee, the share of the insurance on such employee which such beneficiary would have
received if living will, except as may be otherwise specifically provided by the employee, be payable
equally to the remaining designated beneficiaries, if any, who survive the employee. If no designated
beneficiary survives the employee, the amount of insurance will be payable to the employee's executors or
adm inistrators .
C. An insured employee may elect, or in the absence of an election by the employee the beneficiary may,
after the death of the employee, but before any payment is made, elect that the insurance be paid, in lieu
of in one sum in equal annual, semi-annual, quarterly, or monthly installments payable at the Insurer's
Home Office in Dallas, Texas, of a fixed amount (which shall not be less than $5 per month per $1,000 of
insurance payable nor less than $10 per month regardless of the amount of insurance payable) until the pro-
ceeds with accumulated interest at the rate of 2-1�2°lo per annum are exhausted, the final installment to be
the balance of the proceeds and accumulated interest. The election must b� in writing filed at the Home
Office of the Insurer through the employer. The first installment shall be payable immediately upon re-
ceiptof due proof of the employee's death and subsequent installments shall be paid periodically in accord-
ance with the selected frequency of payment. At the death of any payee to whom proceeds have become
payable in installments, the then remaining balance of such proceeds with accumulated interest shall be
paid in one sum to the executors or administrators of the payee unless other provisions shall have been pre-
viously made with the approval of the Insurer, This option may be elected only with the consent of the
Insurer if the payee is a corporation, association or trustee.
C_
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7506-1260
AR7ICLE VII - EXT�NDEb INSURANCE ��NEFIi
A. If the employee, while insured and while under age sixty, becomes totally disabled
from bodi ly injury or disease, thereby being prevented for a period of at least six
months from performing any work or engaging in any occupation for compensation or
profit, the employee's insurance hereunder will be continu�d without payment of pre-
miums, subject to the further provisions of this Article VII.
B. The benefits of this Article shall not apply unless written proof of such total disability
is submitted by or on behalf of the employee to the Insurer at its Home Office after the
said six months and within twelve months following the onset of such total disability.
Upon submission of such proof and unless within thirty days the Insurer rejects such
proof as unsatisfactory, this Extended Insurance Benefit shall become operative, relat-
ing back to the first premium payment becoming due after the date of onset. There-
after, the Insurer may require successive satisfactory proofs of continuance of such
total disability by written requests mailed to the disabled employee at his last address
of record with the Insurer, provided that such requests may not be made more often than
at intervals of three months. If satisfactory proofs of continuance are not received by
the Insurer within thirty days after any such requests, the Insurer shall so notify the
disabled employee by registered mail; and the benefit will automatically expire unless
satisfactory proof is received within thirty days after the mailing of such notification.
C. The original proof of total disability must be furnished in writing to the Insurer on the
initiative of the disabled employee or his personal representative without the necessity
of the Insurer's requesting any such proof.
D. The amount of insurance to be extended under this Extended Insurance Benefit will be
the amount in force hereunder on the life of the particular employee at the date of on-
set of the disability, in accordance with the Schedule of Insurance in Article V, and it
shall continue during the remaining period of total disability; provided that on the pre-
mium due date immediately following the disabled employee's attainment of age sixty-
eight (6�), he shall be deemed fo be a retired employee, and the amount of insurance
hereunder shall become that fixed by the Schedule of Insurance.
E. The Insurer has the right to have the employee examined at any time or times during the
period of claimed disability; and this benefit shall expire immediately and without notice
if at any time consent to make such examination is refused by the employee, his physi-
cian, or his beneficiary.
F. If this benefit expires as provided in Section B or E of this Article VII, insurance of such
employee will be continued hereunder only if regular premium payments for him are
promptly resumed; but in the alternative, if his employment with the employer has then
been terminated, he will be entitled to apply for a policy of life insurance in accordance
with the Conversion Privi lege (Article IX) of this pol icy as though employment had ter-
minated at the date of expiration of this benefit.
G. This Extended Insurance Benefit does-not apply to any empioyee who has attained his
sixti_eth_birthday at the date total disab'i.lity commences.
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ARTICLE VIII - TERMINATION OF INDIVIDUAL INSURANCE
A. The insurance on any employee shall automatically terminate immediately upon the earliest of the follow-
ing dates:
1. The date of termination of his employment with the employer, or membership in the class or classes
eligible for coverage under this policy;
� 2. The effective date of an amendment to this policy which terminates the insurance of any class of em-
ployees to which the individual employee belongs;
3. The date of termination of this policy;
Il
4. The date of expiration of the last period for which he has made any required contribution toward pay-
ment of premiums, except as otherwise provided in Article VII of this policy.
B. Cessation of active work by the employee shall be deemed termination of employment; provided that if the
cessation of active work is on account of (a) sickness or injury or (b) being temporarily laid off or having
been granted a leave of absence, then in any such event employment of any such employee shall automati-
cally and without notice terminate when premium payments for his insurance are discontinued by the em-
ployer acting according to rules which preclude individual selection, but in no event shall the insurance
on any employee who has been temporarily laid off or been granted a leave of absence be continued by
payment of premiums beyond the end of the policy month following that during which leave or lay-off
commences .
� - - _ _ _ _ _ . _ _ -�,--- . _ - ' I�
7508-1260
t
ARTICLE IX - CONVERSION PRIVILEGE
A. If the insurance, or any portion of it, on a person covered under this policy ceases because of termination
of employment or of inembership in the class or classes eligible for coverage under this policy, such person
shall be entitled to have issued to him by the Insurer, without evidence of insurability, an individual pol-
icy of life insurance without disabi lity or other supplementary benefits, provided written application for the
individual policy is made, and the first premium thereon paid to the Insurer, within thirty-one days after
such termination, and provided further that,
' 1. the individual policy shall be on any one of the forms, except term insurance, that shall be selected
by the employee from among the forms then customarily issued by the Insurer at the age and for the
amount applied for;
2. the individual policy shall be in an amount not in excess of the amount of the employee's life insur-
ance under this policy which ceases because of such termination;
3. the premium on the individual policy shall be at the Insurer's then customary rate applicable to the
form and amount of the individual policy, to the class of risk to which the employee then belongs, and
to his age attained on the effective date of the individual policy; and
4, any individual policy issued under the conversion privilege will take effect at the end of the thirty-
one day period during which application for the individual policy may be made and shall be in lieu of
all benefits under the group policy.
B. If this policy terminates, with respect to all employees or with respect to any class or classes of insured em-
ployees, the employee will, if he was insured under this policy at the date of such termination, and if he
has been continuously insured under this policy for at least five years prior to such termination, and if his
insurance under this policy, or any portion of such insurance, ceases because of such termination, be en-
titled to the conversion privilege above described as though his employment had terminated on the date of
such termination, except that the amount of the individual policy will not exceed the smaller of (a) the
amount of the employee's life insurance under this policy which ceases because of such termination or
amendment of this policy less the amount of any life insurance for which he is or becomes eligible under any
group policy issued or reinstated by the Insurer or by any other insurer within thirty-one days after such dis-
continuance, and (b) $2,000.
C. If an insured employeedies within thirty-one days after termination of his insurance and while he is entitled
to have an individual policy issued to him under the conversion privilege and before any such individual
policy has become effective, the amount of life insurance which the employee is entitled to have issued to
him under such individual policy will be payable as a claim under this policy, whether or not application
for the individual policy or the payment of the first premium therefor has been made.
L
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7509-1260
ARTICLE X - GENERAL PROVISIONS
A. Individual Certificate. The Insurer will issue to the employer for each insured employee an individual cer-
tificate setting forth a statement as to the insurance protection to which he is entitled, to whom the insur-
ance benefits are payable and the provisions of the Article of this policy entitled "Conversion Privilege."
B. Renewal. This policy may be renewed from year to year on anniversaries of the policy date, but continu-
ance of the insurance hereunder shall be conditioned upon payment of premiums at such rates as may be
determined by the Insurer. The Insurer may, at its option, refuse renewal if the number of employees in-
sured hereunder is less than ten (10) or less than seventy-five percent (75%) of the total number of employ-
ees eligible, or if employees are contributing to the payment of premiums at a rate in excess of seventy-
.. five percent (75%) of the average premium.
C. Gender. Use herein of a personal pronoun in the masculine gender shall be deemed to include the feminine
unless the context clearly indicates the contrary.
D. Incontestability. This policy shall be incontestable after two years from date of issue except for non-pay-
ment of premiums. No statement made by any person insured under this policy relating to his insurability
shall be used in contesting the validity of the insurance with respect to which such statement was made
after such insurance has been in force prior to the contest for a period of two years during such person's
lifetime nor unless it is contained in a written instrument signed by him.
E. Non-assignability. The insurance and any benefits provided hereunder are not assignable.
F. Misstatement of Age. In the event the age of any person insured under this policy has been misstated the
amount of insurance for such person shall be that determined in accordance with the terms of this policy,
and there shall be an equitable adjustment of premiums made so that the employer shall pay to the Insurer
the actual premiums at the true age of such employee.
G. Insurance Data; Inadvertent Error.
1 . The employer shall furnish the Insurer with the names of all employees initially insured, of all new em-
ployees who become insured, and of all employees whose insurance is cancelled or changed, together
with all data necessary for the calculation of premiums.
2. Failure or omission on the part of the employer to furnish the Insurer the information specified in the
paragraph above shall not deprive such employee of insurance or affect the amount thereof; nor shall
failure to report the termination of insurance of any employee be construed as involving or affecting
.. the continuation of such insurance beyond the date it would otherwise terminate in accordance with the
terms of this policy, but in either such event, an equitable premium adjustment shall be made between
the employer and the insurer upon discovery of the error.
H. Notice of Claim. Written notice of the death of the employee while covered under this policy, either
while in the active service of the employer or during a period when the extended insurance benefit is in
effect, must be given to the Insurer within twelve months after the date of death; if such notice is not given,
... the Insurer will not be liable for any payment on account of such death.
I. Contract; Amendments.
1 . This policy and the application of the employer therefor, a copy of which is attached hereto and the
applications of employees, if any, shall constitute the entire contract. All statements made by the
policyholder or by the persons insured shall be deemed representations and not warranties, and no
statement made by any person insured shall be used in any contest or in defense of a claim hereunder
7510-61263
unless a copy of the instrument containing the statement is or has been furnished to such person or his
beneficiary.
2. This policy may be amended or changed at any time, subject to the laws of the jurisdiction in which
it is delivered, without the consent of the employees insured hereunder or of their beneficiaries by
written agreement between the employer and the Insurer. Only the President, a Vice President, the
Secretary or an Assistant Secretary of the Insurer has the power to change, modify, or waive the pro-
visions of this policy, and then only in writing done at the Home Office. The Insurer shall not be
bound by any promise or representation heretofore or hereafter made by or to any agent or person other
than specified above.
J. Reserve Basis. The reserve on this policy shall be based on the Commissioners 1941 Standard Ordinary
Mortality Table with interest at 3% per annum.
Supplementary Contract Providing
ACCIDENTAL DEATH, DISMEMBERMENT AND LOSS OF SIGHT BENEFITS
Attached to and made a part of Policy No. 21090 & 21091 (herein called the policy)
issued by
GROUP LIFE AND HEALTH INSURANCE COMPANY
to
CITY OF FORT WORTH
Fort Worth, Texas
Subject to all provisions set forth in this supplementary contract and all applicable provisions of
the policy not in conflict herewith,
THE INSURER AGREES TO PAY
the benefit designated in the following Table of Losses, immediately upon notice and due proof
as required herein,
(a) That any employee shall have sustained accidental bodily injuries,
(b) While the policy and this supplementary contract are in force,
(c) Resulting directly in a loss stipulated in the Table,
(d) Which loss occurred within ninety days from the date such injuries
were sustained.
This benefit shall be in addition to any benefit payable under the policy for loss of life.
TABLE OF LOSSES
In event of loss of: The amount of the benefit shall be:
Life The principal sum
Both Hands The principal sum
Both Feet The principal sum
_ Sight of Both Eyes The principal sum
One Hand and One Foot The principal sum
One Foot and Sight of One Eye The principal sum
One Hand and Sight of One Eye The principal sum
One Hand One-half the principal sum
One Foot One-half the principal sum
_ Sight of One Eye One-half the principal sum
The amount of principal sum on each employee shall be the same as shown in the "Schedule of
Insurance" in the policy.
With respect to hands and feet, "loss" shall mean dismemberment by severance through or above
the wrist or ankle joints; with respect to eyes, "loss" shall mean the entire and irrecoverable loss
of sight beyond remedy by surgical or other means.
Form No. SC-AD&D-1-5-61 7516
LIMITATIONS AND EXCLUSIONS
The total amount payable hereunder for losses resulting from any one accident shall in no event
exceed the Principal Sum.
No benefit will be paid hereunder for any loss which results directly or indirectly, wholly or
partially from (a) suicide or attempted suicide, or intentionally self-inflicted injury, while sane
or insane; or (b) disease of the body or mental infirmity, or as a result of medical or surgical —
treatment or diagnosis therefor; or (c) ptomaines or bacterial infection (except pyogenic infection
which shall occur through or with accidental cut or wound); or (d) war or insurrection or any act
attributable thereto; or (e) travel or flight in any aircraft while a member of the crew thereof, or
while engaged in any way in the operation of the aircraft, or while giving or receiving any kind
of training or instruction .
PREMIUMS
The premium rate for the first policy year shall be $0.06 per month for each one thousand dollars
($1 ,000) of principal sum. The Insurer shall have the right to change the premium rate on any
policy anniversary. The premium for this supplementary contract shall be calculated by multi-
plying the aggregate amount of principal sum in force on the premium due date by the premium —,
rate then applicable.
SUPPLEMENTARY GENERAL PROVISIONS
1 . Written notice of injury on which claim is based must be given to the Insurer within twenty
days after the date of the accident causing such injury. Such notice given by or in behalf
of the employee to the Insurer at its Home Office in Dallas, Texas, or to any authorized
agent of the Insurer, with particulars sufficient to identify the insured employee, shall be
deemed to be notice to the Insurer. Failure to give notice within the time provided herein —
shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably
possible to give such notice and that notice was given as soon as was reasonably possible.
2. The Insurer, on receipt of such notice, will furnish to the employee or to the Employer for
delivery to the employee, such forms as are usually furnished by it for filing proofs of loss.
If such forms are not so furnished within fifteen days after receipt of such notice by the In-
surer, the employee shall be deemed to have complied with the requirements hereof as to
proof of loss upon submitting, within the time fixed herein for filing proofs of loss, written
proof covering the occurrence, character, and extent of loss for which claim is made.
3. Written proof of loss must be furnished the Insurer at its said Home Office within ninety
days after the date of the loss for which claim is made. Failure to furnish such proof within —
such time shall not invalidate nor reduce any claim if it shall be shown not to have been
reasonably possible to furnish such proof and that such proof was furnished as soon as was
reasonably possible.
4. The Insurer shall have the right and opportunity to examine the person of the employee when
and so often as it may reasonably require during the pendency of a claim hereunder and also —
the right and opportunity to make an autopsy in case of death where it is not prohibited by
law.
5. All indemnities provided hereunder will be paid immediately upon receipt of
due proof .
6. The benefit for loss of life of the employee is payable to the beneficiary if sur-
viving the employee, otherwise to the estate of the employee; all other benefits
are payable to the employee .
7. No action at law or in equity shall be brought to recover on this supplementary
contract prior to the expiration of sixty (60) days after proof of loss has been
filed in accordance with the requirements hereof, nor shall such action be brought
at all unless brought within two (2) years from th� expiration of the time within
which proof of loss is required.
�. If any time limitation of this supplementary contract with respect to giving notice
of claim, furnishing proof of loss or bringing an action at law or in equity is less
than that permitted by the law of the state in which the employee resides at the
time this supplementary contract is issued, such limitation is hereby extended to
agree with the minimum permitted by such law.
9. Wherever the term "employee" is used in this supplementary contract, it shall
mean only active employees; and in no event shall it be construed to mean re-
tirees.
IN WITNESS WHEREOF, the Insurer has caused this Supplementary Contract to be executed
at its Home Office in Dallas, Texas, to become effectiv� on the lst day of July ,
1965 .
Secretary
�
�_
President
/
�� � . ���o� � �_ _ _ -
Countersigned: , " '
Executive Vice-President
G0H
Application Is Hereby Made to
GROUP LI�.� AND H�ALTH INSURANC� COMPANY
Dallas, Texas
by �`�.j"i�' ('�F Et�t�I �a`C�RTFI _ a . .
(Name of Company) (Type o Organization)
whose main office address is�1 �►NeSt lOth 5� Fprt b`b'nrth _ T�±xc�s ,
for a Renewable Term Group Life Insurance Policy
[� with Full Accidental Death, Dismemberment and Loss of Sight Benefits Supplement.
❑ with Non-Occupational Accidental Death, Dismemberment and Loss of Sight Benefits Supplement.
� without Accidental Death, Dismemberment and Loss of Sight Benefits Supplement. fpf I'etil'@C.'S
� Classes are to be as follows:
��
Description
See Speciai R�presenta#ions
Amount of Insurance
If employment is continued after age N� , benefits shall be reduced to i� 4 %.
The coverage shall relate to the employees of the following affiliates of the Applicant, as well as to the Applicant's
direct employees:
PJone
� Those employees who, on the proposed effective date of the Policy, have been employed for � days are to be
eligible for coverage; and thereafter employees shall become eligible on completion of—�_�__days of employment.
The Applicant certifies that at the date of this Application there are ��7�j employees eligible to make application
for coverage, and requests that the Policy become effective on— -���y 1 -- —, 19 6�,
� provided 75% of the eligible employees have then furnished application for coverage thereunder.
The Policy Anniversaries shall be Jul !�1 , 19 66 , and the corresponding date in
each year thereafter for as long as the Policy is in force.
(continued on reverse side)
•
The Applicant will provide payroll deduction facilities for the employee's portion of the monthly premiums. The
employee's portion will beA5Life Insurance, andAS-526 30111CXXXXIMEI Pm
for the Accidental Death, Dismemberment and Loss of Sight Benefits Supplement. The Applicant will pay the difference
between the total rate and the employee's portion. Changes in average premium rate will be absorbed by the Applicant
unless otherwise stated below.
The following special representations and/or conditions shall become a part of the whole Policy (if additional space is
needed, attach supplement sheet):
Schedule of Insurance:
Class A Employees earning less than $3,000 per year $1,000.00
Class B Employees earning at least $3,000 but less than $6,000 per year $3,000.00
Class C Employees earning $6,000 or more per year $5,000.00
Class C Retirees earning less than $3,000 per year immediately prior to
retirement $1,000.00
Class E Retirees earning at least $3,000 but less than $6,000 per year
immediately prior to retirement $2,000.00 _
Class F Retirees earning $6,000 or more per year immediately prior to
retirement $3,000.00 _
At age 68, insurance under Extended Benefit reduces to retiree level .
The Policy shall be identified by two policy numbers for billing convenience.
This Application is executed in duplicate, one counterpart being delivered to Group Life and Health Insurance Company,
and the other to be attached to the Policy, if issued. _
CITY OF FORT WORTH
Full or Corporate Name of Applicant
by 1/sem
4.11..
Signature and Title
Dated at Fort Worth, Texas /fitness:
on Juno 9
gid r.
Representative of the Insurer
PPdeo v60 S 'To F R M ANIS �.� 6-�i 6;Ty;
G. App.-1A ->e 7511-M563
Ci ry grToRovt,y
C� r ov Lif e� H e�, lth
p �
� ��
affiliated with
�� �a BLUE CROSS�
It Group Hosp/fal Serv/ce, /nc.
7513-1260
t
�l��I"Y �ECRE�6��Y
coi�;-r►,,n�c�- No.�"��.y.e,
GP.OUP HOSPITAL SERVICE, INC.
Da I Ias, Texas
(herein called the Plan)
has issued this
NON-CANCELLABLE, COMPREHENSIVE MAJOR MEDICAL CONTRACT
N O. 21090 & 21091 , to
CITY OF FORT WORTFi
Fort Worth, Texas
(herein called the Employer)
As of July 1, 1965 (herein called the contract date)
and thereby agrees to provide the benefits detai led herein,
�
� all in accordance with the conditions and provisions hereof, including those set out
�� on the following pages which are a part of this contract as fully as if recited over
the signatures hereto affixed.
This contract becomes effective on the contract date, and is issued in consideration
� of the application herefor made by the Employer and of the timely payment of pre-
� miums as provided for herein. It will be continued in force, subject to the Employer's
right of termination, for so long as the minimum employee-participation is maintained,
as set out in the application herefor.
IN WITNESS WHEREOF, the Plan has caused this contract to be executed at its Home
Off ice in Da I las, Texas .
i
i ,�% � / /�.
i �/iiGr����
,, � ,�
Presi dent
�
, , : , % �/ ,_' %
�- � ' r _ _
Secretary %
Countersigned: �; � �,_ � ��%,Y-f�
� ` ,� �� - � . ,'
Executive Director
i;lili � ,;; i1l�:�%
1i,
G
See Art. XI���
Secn_ (� ,!'
ARTICLE I — DEFINITIONS
AS USED HEREIN:
A. EMPLOYEE means a person directly employed on a full time basis in the regular
business of and compensated for services by the Employer or a former employee
who has been retired under the Employer's established retirement plan.
� B. DEPENDENT means an employee's spouse, and any unmarried child under nine-
teen years of age, for whose coverage application has been submitted by the em-
' ployee and accepted by the Plan. An unmarried child between the ages of 19
and 22, inclusive, who is a full time student and dependent upon the employee
for his support, shall also be considered a dependent.
a11V1 l�I� !� �� �'';i
;�
See Art. Xlr�
Sec. __E _',�
C. PARTICIPANT means an employee or a dependent, as above defined.
D. PHYSICIAN means the attending physician (other than a hospital resident or in-
terne) who is licensed to practice medicine and who is a member of his county
medical society or state osteopathic association or is eligible for membership in
such a society or association.
E. CONTRACT ANNIVERSARY means the month and day of any subsequent year
corresponding to the contract date,
F. PRE-EXISTING CONDITION means an abnormal physical or mental condition,
whether active or inactive, existing before the effective date of the participant's
coverage hereunder, including all deformities, ailments or prior injuries which
may thereafter become aggravated by subsequent injury or disease.
G. MEMBER HOSPITAL means any hospital with which the Plan has entered into a
written contract for the rendition of hospital services.
H. NON-MEMBER HOSPITAL means any hospital other than a member hospital which
is listed by the American Hospital Association and approved by the Plan for the
rendition of hospital services on a non-member hospital basis. The term does not
include health resorts, nursing homes, rest homes or any institutions providing pri-
marily convalescent or custodial care.
I. MAJOR MEDICAL BENEFITS means the indemnities provided in this contract.
— — — — — - - _
� - - - - - - - _ _ �
�a
ARTICLE I - DEFINITIONS (Continued)
AMENDEf �'�;
See Art. XI�� �, MEDICAL EXPENSE means charges incurred for the items of service or supply listed
SeC. �� below for the care of a participant, provided such charges are customary and reason-
able in amount and such items are furnished by or at the direction or prescription of
a physician. An expense shall be deemed to have been incurred on the date of ren-
dition of a service for which the charge is made.
1 . Services of physicians.
���'���� � 2. Hospital charges for room and board (whether private or semi-private accom�
S� �•X��r modations are used includin s ecial diets and eneral nursin services ex-
�., � . g p 9 J .
�i.��; ;�. ,_ _.�- cept that the amount of such charges over and above $15 .00 per day sha l l not
be considered hereunder for any purpose.
3.
4.
5.
6.
7.
8.
9.
I�
�
Use of operating, treatment, and recovery rooms.
Care in an intensive care unit of a hospital.
Anesthetics and administration thereof.
X-ray and diagnostic laboratory procedures.
Radiation therapy.
Oxygen and its administration.
Blood transfusions, including cost of blood, blood plasma and blood plasma
expanders.
Drugs, medicines and dressings used in a hospital and those purchased for use
outside a hospital which require a written prescription for purchase.
Services of a qualified professional physical therapist.
12. Services of private duty nurses not related to the patient by blood or marriage:
(a) in or out of a hospital, in the case of Registered Nurses; or (b) in a hospi-
tal only, in the case of Licensed Vocational Nurses.
13. Professional ambulance service to and�or from the nearest hospital adequately
equipped to provide the necessary care.
14. Prosthetic appliances necessary for the alleviation of or correction of condi-
tions arising out of accidental injury occurring or illness commencing after the
participant's effective date of coverage hereunder.
15. Dental treatment necessitated by accidental injury performed by a lic�nsed
dentist or dental surgeon, including replacement of teeth within six months
following the date of the accident.
-- �. .. _ � . .. . _
. - - - - � � _ - - .. -- ' _ ' _ �-�� - - _.�. ,� .f
�
ARTICLE II - EMPLOYEES ELIGIBLE
The following employees are eligible foi- coverage under this contract:
r A. Any employee who on the contract date shall have been continuously employed by the
� Employer for the period of time specified in the application.
B, Any employee not eligible on the contract date but who, subsequently to that date,
shall have been continuously employed by the Employer for the period of time specified
in the application, or in a written notice from the Employer changing such period of
time, delivered to the Home Office of the Plan at least 30 days prior to the effective
date of the change; provided, however, that such change shall apply only to those em-
ployees employed on or after the effective date of the change.
� C. An employee heretofore covered under this contract, whose coverage terminated for
any reason, shall be eligible for new coverage hereunder in accordance with the pro—
visions of Article III, below.
�:� _ _.:- .�,
,�
BOd2-M464
ARTICLE III - EFFECTIVE DATES OF COVERAGE
A. The coverage on each eligible employee shall be conditioned upon his making
application for coverage on a form approved by the Plan and shall, subject to
acceptance of the application, become effective in accordance with the fol-
lowing conditions:
1. For employees eligible on the contract date who make application for
coverage prior thereto, the coverage shall become effective on the con-
tract date .
2. For employees becoming eligible subsequent to the contract date who
make application for coverage prior to the thirtieth day following the
date of employment, the coverage shall become effective on the pre-
mium due date next occurring after the completion of thirty (30) days
continuous employment.
3. If such application for coverage is made after the end of the thirty-day
period immediately following the date of employment or is made after
previous termination of coverage because of failure to make, when due,
any contribution required under this contract, the �mployee must furnish
without expense to the Plan evidence of his insurability satisfactory to
it; but if such evidence is so submitted and the Plan determines the evi-
dence to be satisfactory, the coverage shall become effective on the next
premium due date.
B. Any employee who must furnish evidence of insurability to the Plan as a condition
to obtaining coverage and whose service with the employer terminates without
such evidence having been given shall continue to be subject to the same require-
ment if he is subsequently re-employed.
- - _ �: - -
�o
ARTICLE IV - PREMIUMS
AMENDED-
See Art.X13 A. Continuance of the coverage hereunder shall be conditioned upon payment of premi-
Sec. A urns by the Employer at the Home Office of the Plan in Dallas, Texas in accordance
with the following provisions. The first premium is due on the contract date; subse-
quent premiums are, during the continuance of this contract, payable in advance. Ex-
cept as otherwise provided herein, this contract shall automatically become void if
any premium is not paid when due and payment of any premium shall not maintain the
coverage under this contract in force beyond the day immediately preceding the next
premium due date.
INITIAL SCHEDULE OF MONTHLY PREMIUM RATES
Active Employee $ 4.91
Active Employee and Spouse 13.08
Active Employee and Spouse
and child or children 17.14
Active Employee and child or
children 11 .04
Retired Employee 12.24
Retired Employee and Spouse 24.48
Retired Employee and Spouse
and child or children 28.16
Be This contract shall be non-assessable. It does not share in the earnings of the Plan,
but the Plan reserves the right to change the schedule of premium rates on any con-
tract anniversary, except the first, as applicable to the succeeding year. No such
change shall be made in the rating classification on account solely of any claim in-
curred hereunder, and any such change shall be made uniformly applicable to all em-
ployees within any sub-group or other classification under this contract.
C . Premiums may be paid on a monthly, quarterly, semi-annual, or annual basis as the
Employer may elect, but without discount. Unearned premiums for employees whose
coverage hereunder terminates at other than a premium due date shall be calculated
and refunded from the end of the contract month during which the employee ceased to
be eligible for coverage hereunder.
D. The premium to be paid hereunder shall be determined by multiplying the number of
employees covered for each classification in the schedule of rates then applicable by
the rate for that classification, and totalling the extensions thus obtained.
A . `fes ':34111A51111M
8467-M464
E. A grace period of thirty-one days, without interest charge, shall be allowed for the
payment of each premium except the first. If any premium is not paidwithin the grace
period, this contract shall terminate at the end of such grace period, except that the
contract shall terminate at an earlier date (which is not prior to the end of the period
for which premiums have been paid) provided the Employer shal) have given written
notice ofsuch earlier date oftermination in whichevent the contract shall terminate at
such earlier date. If the contract terminates during or at the end of the grace period ,
the Employer shall be liable to the Plan for payment of a pro rata premium for the time
the contract was in force during the grace period.
;
ARTICLE V- BENEFITS AND PAYMENTS
IA. Subject to the qualifications, limitations and exclusions set forth herein,
the Plan wi II provide benefits for medical expense incurred by the parti-
� cipant, all as detailed in Article VII.
B. Payment of benefits by the Plan to the employee shall constitute full dis-
charge of all responsibility of the Plan to the participant for such benefits.
l
C. Any benefits hereunder payable to the employee shall, if unpaid at his
r death, be paid to the surviving spouse of the employee. If there is no sur-
viving spouse, then such benefits shall be paid to the employee's estate.
D. The coverage and any benefits provided hereunder are not assignable.
� - - - - � -
�- -- _ -- -- --- --- — --- -_- {. -- -
-- � o
ARTICLE VI - MAXIMUM MAJOR MEDICAL BENEFITS
A. Maximum total benefits to be provided any participant hereunder during the
period of the employee's active service with the employer shall be $5,000.00.
B. When an employee becomes classified as a retiree, the maximum total benefits
to be provided him or any participant under his coverage thereafter shall be
$2,500.00.
C. Notwithstanding the limitation set forth in Section A, above, after benefits
hereunder totaling $1,000.00 or more have been paid to or on behalf of an
active employee or any of his dependents, he may apply to the Plan for re-
establishment of the $5,000.00 maximum by furnishing evidence of insurability.
The Plan at its sole discretion shall determine the acceptability of the applica-
tion and prescribe the terms and limitations to govern the participant's future
eligibility for Major Medical benefits.
ARTICLE VII - BENEFITS
A. HOSPITAL BENEFITS. Except as otherwise provided in this Article VII, when any
( participant on or after the effective date of his coverage hereunder shal I incur ex-
l pense of hospital charges consisting of:
L.
1. In-patient: usual hospital services necessary to the treatment of the patient
for use while an in-patient in a member hospital; or
2. Out-patient: services received on the day minor surgery is performed or
within 72 hours after an accident, while an out-patient of a member or
non-member hospital,
the Plan will provide benefits to indemnify the participant against such expense in
an amount up to but not exceeding $300.00 during any calendar year; provided,
however, that when expense as specified in sub-section 1, above, is incurred in a
non-member hospi ta I, the I iabi I i ty of the Plan sha I I be I im i ted to 80°l0 of such ex-
pense up to a maximum of $300.00.
B. MATERNITY BENEFITS. Benefits under this contract for obstetrical care shall apply
only to pregnancies of active employ�es and wives of active employees and only to
pregnancies commencing after the effective date of coverage of the obstetrical
patient. For any pregnancy terminated by normal delivery, the entire benefit shall
consist of payment of all medical expense related thereto, but not exceeding $100.00.
For any pregnancy terminated by other than normal delivery, the benefit shall be as
determined by the other sections of this Article VI I.
C. MAJOR MEDICAL BENEFITS. When any participant, on or after the effective date
of his coverage hereunder and within a calendar year, shall incur medical expense
(other than for pregnancy for which a benefit is provided in Section B) in excess of
the total of:
1. Benefits paid or payable under Section A, above,
2. The deductible, as specified in Section D, below,
the Plan will provide major medical benefits amounting to 80°l0 of such excess.
���N���� D. DEDUCTIBLE. The deductible to be ap,�lied in Section C, above, shall be $50.00
See Art.Xl�� of inedical ex ense incurred b the artici ant during the calendar ear within a
P Y P P Y
����;o,j � three consecutive month period. Any portion of the deductible satisfied during the
last three months of the calendar year may be applied to the satisfaction of the de�
ductible the following calendar year. If two or more participants under the coverage
of one employee hereunder should incur medical expense as the result of injuries sus-
tained in a common accident, then only one deductible shall be applied for both or
all of such participants.
ARTICLE VII - BENEFITS (Continued)
y E. ANTI-DUPLICATION OF BENEFITS. It is hereby declared to be the intent of the
Employer and the Plan that the availability of the benefits herein specified shall be
� contingent upon the absence of other coverage. Any other contract or pol icy under
which the participant holds protection for medical and�or hospital expenses by vir-
tue of his membership in or relation to a particular group in which any employer
� contributes shall be considered "other coverage" within the meaning hereof, whe-
ther issued by the Plan or any other carrier, and whether the benefits are in the
nature of indemnity or prepaid services. The term shall likewise be deemed to in-
I clude any governmental program existing by statutory authority, under which he
is entitled to any benefits provided hereunder. When, therefore, other coverage
applies, the benefits of this contract shall be coordinated therewith and determined
� in accordance with the following subsections of this Section E:
n
The benefits of this contract shall be modified by the provisions of this Section
E only when the other coverage does not have corresponding non-duplication
provisions, or when it has such provisions and
(a) The patient is classified as employee or primary insured under the other
coverage and as dependent under this contract, or as dependent of a
male person under the other coverage and dependent of a female per-
son under this contract; or, if those conditions do not exist,
(b) The effective date of the patient's participation under the other cover-
age is earlier than the effective date of his coverage hereunder.
2. Determination of benefits under this Section E shall be made in relation to each
"case," consisting of all items of inedical expense furnished a participant for
any condition caused by accident or illness.
3. When this Section E is applicable, the benefits of the other coverage shall be
deducted, item by item, from the charges for all items of expense for which
any benefit is provided under Article VII hereof; and the Plan will pay the re-
mainder of the charges for such items; provided, however, that in no event
shall the provisions of this Section be construed to increase the amount of total
benef i ts wh i ch wou I d be payabl e hereunder i n the absence of other coverage .
4. When benef i ts are provi ded by other coverage for certa i n i temi zed servi ces i n
one unallocated amount, they will be deemed to apply pro rata to all such
items. When a deductible amount applies to the benefits of other coverage it
shall be deemed to apply pro rata to each of the benefit factors thereunder.
___ _ _ _
_____ _ �: _
.:
ARTICLE VII - BENEFITS (Continued)
5. The Plan assumes no obligation to discover the existence of other coverage
or the benefits payable under it if discovered, but only to effect to the pro-
visions of this Section E in accordance with information furnished it by an
authoritative source. It shall, however, be entitled to obtain and�or to re-
lease such information as is reasonably necessary to give effect to these pro-
visions, without the consent of or notice to any person; and any person claim-
ing benefits hereunder shall, as a condition precedent to his right of recovery,
furnish to the Plan full information concerning the existence of other coverage
and the benefits thereof.
6. The Plan shall be entitled at any time to recover benefits paid in excess of its
� obligation as determined under the provisions of this Section E, irrespective of
to whom such benefits were paid, from an issuer or provider of the other cover-
age, or a hospital, or any person to or for whom such payment was made, or
from any combination of such sources.
7. When benefits have been paid under other coverage, the Plan shall have the
right, in its discretion, to pay over to the issuer or provider of such other
coverage any portion of the benefits available under this contract which the
Plan may determine to be due in order to give effect to the intent of this Sec-
tion E and corresponding non-duplication provisions in such other coverage.
The amount so paid shall be deemed to be benefits provided under this contract
and, to the extent thereof, the Plan shall be fully discharged from liability
hereunder.
AMEND�p-
See Ar� Xq
Sec. G
�— - - -- -- - -
} �:
0
ARTICLE Vfll - LIMITATIONS AND EXCLUSIONS
The benefits of this contract are not available for:
A. Care for services received or rendered through or in Veterans Administration
facilities; any care for which benefits are, or could upon proper claim be pro-
vided under the Workmen`s Compensation law, or any other present or future laws
enacted by the Legislature of any state, or by the Congress of the United States,
or the laws, regulations or established procedures of any county or municipality
unless there is an unconditional requirement on the participant to pay such ex-
pense without reimbursement.
B. Any condition, disease, or ailment arising out of and in the course of employ-
ment.
C. Diseases contracted or injuries sustained as a result of war, declared or unde-
clared, or any act of war; or service in the armed forces of any country.
D. Services or supplies not incidental or necessary to the treatment of injury or
si ckness .
E. Any care or service rendered for cosmetic purposes not necessitated by accidental
injury.
F. Dental care and treatments, dental surgery or dental appliances unless such charges
are made necessary by accidental injury effected solely through external means
and occurring while the participant is covered hereunder.
G. Eyeglasses or hearing aids or examinations for the prescription or fitting thereof.
H. Charges for expenses in an amount considered by the Plan to be unnecessary and�or
unreasonable .
I. Any services rendered in connection with a routine physical examination or any
diagnostic or evaluation procedure not necessary to the proper treatment of an
abnorma I physi ca I or menta I condi ti on .
J. Any services or care rendered for mental and�or nervous conditions unless confined
as an in-patient in a hospital .
K. Services or supplies not specifically defined as medical expenses.
L. Travel, whether or not recommended by a physician.
M. Convalescent, custodial or sanitariai care or rest cures.
. . -. . ,_. �._..._, -_ ._ .-.. _ - . __ � - -
r �� ,
; - ; �, �
a
ARTICLE VIII - LIMITATIONS AND EXCLUSIONS (Continued)
N. Any services or supplies furnished to a participant more than two years before
charges are reported to the Plan as a medical expense.
O. Any care provided during the course of a hospital stay commencing before or
after the period during which the patient is covered as a participant hereunder.
P. Any medical expense incurred for treatment of an employee's pre-existing condi-
tion during the first six months following the effective date of his coverage here-
under, or any medical expense incurred for treatment of a dependent's pre-exist-
ing condition during the first twelve months following the effective date of his
coverage hereunder; provided, however, that this limitation shall not apply to
employees and depend�nts acquiring coverage hereunder on the contract date,
nor to those who incurred no medical expense for treatment of the pre-existing
condition during a three consecutive month period commencing before and end-
ing on or after the effective date of coverage hereunder.
Q. Maternity care of a retired employee or of any dependent except the wife of an
active (non-retired) employee.
M�N��D -
� �� ��
�, D
AMENDED-
See Art. XI�
Sec. C�
ARTICLE IX - TERMINATION OF COVERAGE
A. The coverage on any employee and his dependents included hereunder shal I auto-
matically terminate upon the earliest of the following dates:
1. The last day of the period for which his portion of the premium has been paid
to the Plan when his employment with the Employer ceases or when his death
occurs;
2. The effective date of an amendment to this contract which terminates the
coverage of any class of employees to which the employee belongs;
3. The date of termination of this contract by:
a. Cancel lation at the request of the Employer,
b. Default in premium payment,
c. Failure of the group to maintain the level of enrollment required under
the minimum employee-participation table set out in th� application
herefor, but in such event the contract will not terminate if within
thirty days after the Plan shall notify the Employer of the enrollment
deficiency it is remedied by the submission of additional applications
for coverage of eligible employees sufficient to meet the minimum
participation requirements,
d. Operation of law;
4�. The date of expiration of the last period for which he has made any required
contribution toward payment of premiums.
B. The coverage on any dependent child of an employee included hereunder shall auto-
matically terminate at the end of the contract month in which such child becomes
nineteen years of age (unless he is a full time student, in which case his coverage
shall cease as provided in the other applicable sections of this Article IX), or mar-
ries prior thereto.
C. When the coverage on a dependent child of an employee fails to terminate as pro-
vided in Section B, above, it shall automatically terminate at the end of the con-
tract month in which he or she becomes twenty-three years of age or marries prior
thereto or ceases to be a full time student.
D. The Plan will refund to the Employer the portion of the premium theretofore paid in
advance for coverage of a child whose coverage has terminated because of age or
marriage, as provided in Sections B and C, above; provided, however, that in case
of termination on account of marriage, the refund wi II not be made as to any period
before the Plan is actually notified of the marriage.
��.
�_. .= - - : _ - . � -: . _;__ . . ._ _. r- -, - = -�- :�� _ . __ _.
0
�
►
L
L.
L
ARTICLE IX - TERMINATION OF COVERAGE (Continued)
E. If any participant's coverage hereunder is terminated by reason of termination of
this contract or cessation of employment and if such participant is then under the
care of a physician for an illness which commenced or an injury which occurred
during the period of coverage hereunder, and further provided that such illness or
injury has caused the participant to be then totally disabled, the liability of the
Plan hereunder shall be extended in relation to that iliness or injury only during
the yearsucceeding the termination, subject to the limitation specified in Arti-
cle VI.
F. Under no circumstances shall the Plan be obiigated to notify any participant of
the termination of this policy or of his coverage hereunder.
,-�_ . . . . . . _ __ - _ _ �_.�.�_ _ ._ . _
=_ _ . . - _ _� :
�:
�
L.
ARTICLE X - CONVERSION PRIVILEGE
A. When coverage for an employee is terminated her�under by reason of cessation
of employment, as provided in Paragraph 1 of Section A of Article IX, above,
he shall have the right of conversion for himself and his previously included de-
pendents to new individual coverage as provided for in Section D of this Article X.
B. When coverage for an employee is terminated hereunder by reason of death, as
provided in Paragraph 1 of Section A of Article IX, above, his or her surviving
spouse, if then included as a dependent hereunder, shal I have the right of con-
version to new individual coverage for himself or herself and the other previously
included dependents as provided for in Section D of this Article X.
C. When coverage for a dependent child is terminated hereunder by reason of mar-
riage or when coverage for a dependent child is terminated hereund�r by reason
of attainment of age twenty-three, as provided in Sections B and C of Article IX,
above, the dependent child shall have the right of conversion to new individual
coverage as provided for in Section D of this Article X.
D. Any person becoming eligible for conversion as provided for in the three preced-
ing sections of this Article X may, within thirty-one days after termination of his
coverage hereunder, submit application for new individual coverage under the
form or forms of inembership agreements then offered by the Plan to conversion
applicants. The agreement applied for will be issued, without requirement of
evidence of insurability, at the conversion premium rates then in effect. The
individual agreement will be made effective as of the day after the date of the
termination hereunder, and full recognition will be extended to the period of
coverage hereunder for the satisfaction of waiting periods and clauses respecting
pre-existing conditions as may be contained in the individual agreement.
- -- - -- - - -
_ - _ _ ;. �.. '
�t
ARTICLE XI - GENERAL PROVISIONS
A. CONTRACT; AMENDMENTS:
1. This contract and the application of the Employer therefor, a copy of
which is attached hereto, and the applications of employees shall con-
stitute the entire contract. All statements made by the Employer or by
the employees covered shall be deemed representations and not warran-
ties, and no statement made by any employee covered shall be used in
any contest or in defense of a claim hereunder unless a copy of the in-
strument containing the statement is or has been furnished to such person
or to his beneficiary.
2. This contract may be amended or changed at any time, subject to the
laws of the jurisdiction in which it is delivered, without the consent of
the employees covered hereunder or of their beneficiaries, by written
agreement between the Employer and the Plan. Only the President, a
Vice President, the Executive Director, the Secretary or an Assistant
Secretary of the Plan has the power to change, modify or waive the pro-
visions of this contract, and then only in wrifing done at the Home Office.
The Plan shall not be bound by any promise or representation heretofore or
hereafter made by or to any agent or person other than specified above.
B. INCONTESTABILfTY: This contract shall be incontestable after two years from
date of issue except for non-payment of premiums.
C. TIME LIMIT ON CERTAfN DEFENSES: After one year from the effective date of
coverage for any employee, no misstatements, except fraudulent misstatements,
made in his application for coverage shall be used to void his coverage or to deny
a claim for benefits on account of inedical expenses incurred after the expiration
of such one-year period .
D. REINSTATEMENT: If default be made in the premium payments for this contract,
the subsequent acceptance of such premium by the Plan or any of its duly authorized
agents shall fully reinstate the contract.
E. NOTICE OF CLAIM: The employee shall give or cause to be given written notice
to the Plan or its duly aufihorized agent within thirty days or as soon as reasonably
possible after any participant incurs medical expense.
F. PROOFS OF LOSS: 'Any medical expense incurred by a participant must be re-
ported to the Home Office of the Plan at Dallas, Texas, by the employee within
ninety days. Failure to give notice or furnish proof within the time specified shall
not invalidate any rights if it shall be shown not to have been reasonably possible
to give such notice or furnish such proof, and that it was done as soon as was
reasonably possible.
�: - --- -- - - _ _ _- - . �, - -
�o
G.
ARTICLE XI - GENERAL PROVIS(ONS (Continued)
TIME OF PAYMENT OF CLAIMS: Benefits payable under this contract for any
loss will be paid immediately upon receipt of due written proof of such loss.
H, PHYSICAL EXAMINATIONS AND AUTOPSY: The Plan at its own expense shall
have the right and opportunity to examine the person of a participant when and as
often as it may reasonably require during the pendency of a claim hereunder and to
make an autopsy in case of death where it is not forbidden by law.
I. LEGAL ACTIONS: No action at law or in equity shall be brought to recover under
this contract unless brought within three years after the date medical expense is
incurred.
J. INDIVIDUAL CERTIFICATE: The Plan will issue to the Employer for each covered
employee an individual certificate setting forth a statement as to the benefits to
which he is entitled, to whom the benefits are payable, and the provisions of the
Article of this contract entitled, "Conversion Privilege."
K.
L.
MEMBER HOSPITAL LIST: The Plan will furnish a current list of inember hospitals
to any employee covered hereunder at any time upon request, without charge.
GEN DER: Use herein of a personal pronoun in the mascul ine gender shal I be deemed
to include the feminine unless the context clearly indicates the contrary.
M. COVERAGE DATA; INADVERTENT ERROR:
1. The Employer shall furnish the Plan an application for coverage executed by
each employee to be covered hereunder, and all information needed to ef-
fect termination and changes in such coverage.
2. Failure or omission on the part of the Employer to furnish the Plan with the
information specified in the paragraph above shall not deprive such employee
of coverage; nor shall failure to report the termination of employment of any
employee be construed as effecting the continuation of such group coverage
beyond the date it would otherwise terminate in accordance with the terms of
this contract; but in either such event an equitable premium adjustment shall
be made between the Employer and the Plan upon discovery of the error.
N. The Plan shall not be liable for any act or omission by any hospital, physician,
their agents or employees, in caring for a participant.
O. Each employee, by making application for coverage hereunder, shall be deemed to
have authorized any physician, nurse or hospital to furnish the Plan full information
and records or copies of records relating to the diagnosis, treatment or care of any
participant included under his coverage, and such authorization shall be treated as
a waiver of all provisions of law forbidding them from disclosing such information
and records to the Plan.
t
r
ARTICLE XII - AMENDMENTS
Effective July 1, 1967
A. Article IV, Section A of this contract is hereby amended by substitution of the
following rates in lieu of the rates previously effective:
SCHEDULE OF MONTNLY PREMIUM RATES
Active Employee
Active Employee and Spouse
Active Employee and Spouse
and ch i Id or ch i Idren
Active Employee and chi Id
or ch i Idren
Retired Employee
Retired Employee and Spouse
Retired Employee and Spouse
and child or children
$ 6.20
T6.37
21 .32
13.�8
12 .24
24.40
28.i6
B. Article VIl of this contract is hereby amended by deleting the wording of Section
C in its entirety and substituting therefor the following:
C. MAJOR MEDICAL 6ENEFITS . When any participant, on or after the effective
date of his coverage hereunder and within a calendar year, shall incur medical
expense (other than for pregnancy for which a benefit is provided in Section B)
in excess of the total of:
�
1. Benefits paid or payable under Section A, above,
° 2. Benefits paid or payable, if any, under Section F, below,
3. The deductible, as specified in Section D, below,
C.
�
r
�
the Plan will provide major medical benefits amounting to �0°l0 of such excess.
Article VII of this contract is hereby amended by adding thereto the following new
Section F:
F. EMERCENCY FIRST AID BENEFITS. When any active employee or dependent
of an active employee receives emergency care furnished by a physician as the
result of accidental injury occurring not more than 72 hours preceding the visit
to the physician, the Plan will provide benefits to indemnify such participant
against the charge for such care in an amount up to but not exceeding $25.00
for any one accident.
r� - - - -- - — __ _ -- - --
- �i
c
ARTICLE XII - AMENDMENTS
Effective July 1, 1967
E. Article I of this contract is hereby amended by deleting the wording of Section D
in its entirety and substituting therefor the following:
D. PHYSICIAN means a person (other than a hospital resident or interne) who is
a Doctor of Medicine, Doctor of Osteopathy, or poctor of Podiatry and who
is a member of his county medical society, state osteopathic association or
state podiatry association or eligible for membership in such society or associa-
tion; the term shall not be deemed to include a Doctor of Dentistry, a Doctor
of Optometry, or a Doctor of Chiropractic, nor a Doctor of Medicine, Osteo-
pathy or Podiatry ineligible for membership in his respective society or associa-
tion. The terms Doctor of Medicine, Doctor of Osteopathy, Doctor of Podiatry,
Doctor of Dentistry, Doctor of Optometry, and a Doctor of Chiropractic, as
used herein, shall have the meaning assigned to them by Article 3.70-2,
Subsection B of the Insurance Code of Texas.
F. Article I, Section J, of this contract is hereby amended by deleting the wording of
Subsection 1 in its entirety and substituting therefor the following:
1. Services of Physicians except that the charge for a service of a Doctor of
Podiatry shall be considered Medical Expense only if such service is an
operative or cutting procedure or the setting of a fracture or dislocation.
G. Article VIII of this contract is hereby amended by the addition of the following new
Section R:
R. Any services of a Doctor of Chiropractic, Doctor of Dentistry or poctor of
Optometry .
H. Article I, Section A of this contract is hereby amended by the addition of the follow-
i ng sentence:
Disability Retirees shall be classified as Retirees under the terms of this
contract.
GROUP HOSPITAL SERVICE, !NC .
j / j.
-� � =-
� �
� �; ,1.�.� , , � :e_ � � . � r�. � r .t �
resident
�-- � - - r _, �_ _ , _ -�: T � -- - ,
_ - - - - - - -- - - - � _ �: _ ---
�o
ARTICLE XII - AMENDMENTS
Effective July 1, 1967
(Continued)
D. Article VIII of this contract is hereby amended by adding thereto the following new
Section R:
R. Emergency care furnished by a physician to a retired employee or to a dependent
of a retired employee.
GROUP HOSPITAL SERVICE, INC .
-(-)
r--
Executive Director
s.
ARTICLE XII - AMENDMENTS
Effective July 1 , 1967
E. Article I of this contract is hereby amended by deleting the wording of Section D
in its entirety and substituting therefor the following:
D. PHYSICIAN means a person (other than a hospital resident or interne) who is
a Doctor of Medicine, Doctor of Osteopathy, or Doctor of Podiatry and who
is a member of his county medical society, state osteopathic association or
state podiatry association or eligible for membership in such society or associa-
tion; the term shall not be deemed to include a Doctor of Dentistry, a Doctor
of Optometry, or a Doctor of Chiropractic, nor a Doctor of Medicine, Osteo-
pathy or Podiatry ineligible for membership in his respective society or associa-
tion. The terms Doctor of Medicine, Doctor of Osteopathy, Doctor of Podiatry,
Doctor of Dentistry, Doctor of Optometry, and a Doctor of Chiropractic, as
used herein, shall have the meaning assigned to them by Article 3.70-2,
Subsection B of the Insurance Code of Texas.
F . Article I, Section J, of this contract is hereby amended by deleting the wording of
Subsection 1 in its entirety and substituting therefor the following:
1 . Services of Physicians except that the charge for a service of a Doctor of
Podiatry shall be considered Medical Expense only if such service is an
operative or cutting procedure or the setting of a fracture or dislocation.
G. Article VIII of this contract is hereby amended by the addition of the following new
Section R:
R. Any services of a Doctor of Chiropractic, Doctor of Dentistry or Doctor of
Optometry.
H . Article I, Section A of this contract is hereby amended by the addition of the follow-
ing sentence:
Disability Retirees shall be classified as Retirees under the terms of this
contract.
GROUP HOSPITAL SERVICE, INC .
resident 7v
ARTICLE XII - AMENDMENTS
Effective July 1, 1968
I. Article I, Section J of this contract, as amended, is hereby amended by deleting the
wording of Subsection 2 in its entirety and substituting the following:
2. Hospital charges for room and board (whether private or semi-private accom-
modations are used), including special diets and general nursing services, ex-
cept that the amount of such charges over and above $18.00 per day shall not
be considered hereunder for any purpose .
J. Article VII of this contract, as amended, is hereby amended, by deleting the wording
of Section D in its entirety and substituting the following:
D. DEDUCTIBLE. The deductible to be applied in Section C, above, shall be $50.00
of inedical expense incurred by the participant during the calendar year. Any
portion of the deductible safiisfied during the last three months of the calendar
year may be applied to the satisfaction of the deductible the following calendar
year. If two c�� more participants under the coverage of one employee hereunder
should incur medical expense as the result of injuries sustained in a comr�non
accident, then only one deductible shall be applied for both or all of such
partic ipants.
;- - - --� -- - _ - __- ---
� , - .
GROUP H OSPITAL SERVICE , 1 NC .
� , /� J , �,
/ � /
� � Lt'. '1'�v' � ; �r �+���- :�G`-s�-�yi� r
President
:r�
�
Application Is Hereby Made to
�t
,� � GROUP pSPITAL,
�'�r,t�tce, IN�.
Dallas, Texas
bv City of Fort Worth
whose main office address is �`9t'1' °t�'�Of"�{'i� �E:XCIS
for a group A"i2S�iYr�?Fi�S�4�'b�4���'s��P6`�g�sx.comprehensive major medica6 contract as fo�i�sws:
�3!}t�.�0 primc�ry hc�s�irs�i E�e��fit
�lUO.C}� mctternity be�efi�
��L�:Ot� ��e�,��;�iF�l�, €�t�/�� �t�aje�r meciiee�l vvith �5,(3�i1 t�:? iif.etime, aximu�j1 .
The eligibility period provided for in Article II, Section A of the Contract is to be onE monf�5 COt1�'inuaus s�rviee
and in Section B, �@�u �,�,�i�e�'s �.oni•inuc�us service.
The coverage shall relate to the employees of the following affiliates of the Applicant, as well as to the Applicant's direct
employees (if none, write "NONE"):
The contract, and the supplement if applied for, shall become effective on �UOy' �' ���i;� , provided
a sufficient number of eligible employees have then furnished applications for coverage thereunder, in accordance with
the mini u participation tables set out on the reverse. The Employer represents that at the date of this Application there
are ��o employees eligible to make application for coverage.
The Employer will pr vide payro I �jeduction facilities for th e employ es' portion of the premiums, and will contribute the
following portion: �an�i'pCt ��`°�{} — 45°a af emplO eC: O�t�ja COSt
�onftract �1491 � 1(FO% of em��ayee only cost
The following special representations and/or conditions shall become a part of the whole contract (if none, write "NONE";
if additional space is needed, attach supplement sheet):
��
`ihe c��itroc�r shc�ll be id�ntifi�d by two contrnct nurr��ers for �aillirzg cesriv�:r�ienc�.
This application is executed in duplicate, one counterpart being delivered to Group Hospital Service, Incorporated and
the other to be attached to the Contract with its Supplement, if any is applied for.
Full or corporate name of Applicant
/�
� / � . ��,�- E���1L�'�j-4=� �
by ��.�� ��,� l.� �� ✓ �
Dated at F�t Wort� r T�xas / �
Signature and title
On June 9� , 19�� , Witness:
�-�F'.�n �✓� L i-�s i� f=d�� .��vv .L���.�� i ry,�
//l � �9
8055•M762. - � `/r` ���/�'�'�L�L �/ ��%
' � i� %Y � T"�"o � ni�j�
����•'9L�:�����t.r_../
Representative of the Plan
ii,4*
GROUP I IOSPITAI-Swuvee, INC.
Dallas,Texas
Application is hereby made to AMEND, effective July 1, 1967
NON-CANCELLABLE EXPERIENCE RATED HOSPITALIZATION CONTRACT NO. 91090 8. 21091 as follows:
By providing that when any active employee or dependent of an active employee receives
emergency care furnished by a physician as the result of accidental injury occurring not
more than 72 hours preceding the visit to the physician, the Plan will provide benefits to
indemnify such participant against the charge for such care in an amount up to but not
exceeding $25.00 for any one accident. Any benefits paid or payable for such care shall
be added to the Hospital Benefits provided for in Section A of Article VII of this contract
_ in calculating such participant's Major Medical benefits under the contract. This emer-
gency care benefit is not available to former employees who have been retired under the
Employer's established retirement plan or their dependents.
The amended schedule of monthly premium rates shall be as follows:
Active Employee $ 6.20
Active Employee and Spouse 16.37
Active Employee and Spouse and child or children 21 .32
Active Employee and child or children 13.88
With this Application for Amendment, we submit the Contract to you for the appropriate endorsement.
1 This Application for Amendment is executed in duplicate, one counterpart being delivered to Group Hospital Service,
Incorporated and the other to be attached to the Contract.
CITY OF FORT WORTH
Full or corporate name of Applicant
011
by /
OF"— Signature and title
Dated at Fort Worth, Texas /
Witn-
On June 16 , 19 67
�� Representativ of the Plan
8264-M1263
r
0
GROUP OSPITAL, �,��e IN .
s,�
Dallas, Texas
Application is hereby made to AMEND, effective �U�� �� 1967
NON-CANCELLABLE EXPERIENCE RATED HOSPITALIZATION CONTRACT NO. 2��p as follows:
By amending the definifiion of Physician to inClude Doetor of Podiatry c�nd by amending the
definition o� Medical Expense to limit the services of a C7octor of Podiatry fo op�rative
and cutfiing procedures or setting of fractvres and dislocafior�s.
�Iso by providing that disability retirees shali be classified as re'rirees und�r fh� terms
of this cantFact.
The amended scliedule of monthly premium rates shall be as follows:
With this Application for Amendment, we submit the Contract to you for the appropriate endorsement.
This Application for Amendment is executed in duplicate, one counterpart being delivered to Group Hospital Service,
Incorporated and the other to be attached to the Contract.
� �ITY C�F ��RT �r�(Z`i;i
Dated at
8264-M1263
Fort V1�orth, Texas
�
� Full or corporate name of Applicant
�---� � � � !
by ' < �- /« _ . .f , � / .
�l_ �t'-�� 4� • �� l� >'L: � t �G > ,�C'!%Ll'lCij �
� � r Signature and'title
�'' �
Witness: �� � i
���; =�CG'i`L�� /C� , �� ' /i'
:/J>��Lc,�_.j'i�
— ,
Representative of ihe Plan
, ��
� � p
GROUP
OSPITAL,�'�,���, IN�.
Dallas, Texas
Application is hereby made to AMEND, effective J��y � n ��6�— ,
NON-CA�CELLABLE EXPERIENCE RATED;'HOSPITALIZATION CONTRACT NO. 21�!`�% � 2��f�� as follows:
;i,
; � ���
Ry cheanc�in� t�i� h�s�atal;'ro�rn Eirnit f'ro�i $15.�1J tv $1�.�:i�.
�
�y chas���in� E�n� �aio�'�M��ica�l,'de�duct�bie �:eriocf frorn 3��di�fF�s to 3G5 �c�ys.
/'/ �/
,'
� i
The amended schedule of monthly premium rates shall be as follows:
i+lo Chan�e.
With this Application for Amendment, we submit the Contract to you for the appropriate endorsement.
This Application for Amendment is executed in duplicate, one counterpart being delivered to Group Hospital Service,
Incorporated and the other to be attached to the Contract.
CIiY t�F F���tT �/�s 1'H
Full or corporate name of Applicant
Dated ar— �art Worth 5 ��"XaS
On L�U �`l � � 19 C' �
8264-M1263
by
1 � Signafure and tit�e /%`/�
L��
Witness: ��1/'`Z �/ ,L��'l/i/L -� f'�
t� �
Representative of The Plan
�
`.
' ,
.. . � �
� EX�R1C1�10E ZAiiNG AGR��tMEN�' �
if�is Ac�re�men; is en�Yer�d +ni�o �y ard i��;i•weer�
GROUP HOSP1iAl: Sc:�.ViC�, fNC. (ncrcir�c�f�er ca-liFd I3(ue Crussj
a r�d
GROUP LiFE & hEALiH INSURA�IC� CO. ('neresr�af�er cuilea 3lue Snielci}
. ' . Da f las, i exas •• ,
� , and .
� � ; , : , ,
.,
� ' � CfTY O�� �OR� WO;:ii-i
� For� Wnr�h, 1'exas
• ' � (��ereina�+er ca(1ed tne �m�loyer) `
�
for �l�e �xir�se of de��rmininc,� t-hE'fir�ai ccr.sidarai�ion �o �ae pai� by the Ern�iGyer �v; ��-�e CGrnjfilGG
COVG'1'C;CCS Oi �'ji2ii �xper�ence Rafed GiOUp HOS�Oitp'i�.aiion C011�'i"CC1'S pt1Ci MQ�O1" MGd1CCl SU��+c�:l��+�'5
No. 2i090 and 21091 and Experience Rq1'eG Group tv�,edical�Sur�ical Insurar��e� �oi�cies �o. 2IGi`�
ar�d 21091 (he�einafter collectivefy cal(ed "neali•h Coverare") unu' Grou� l�rm Li�c �nsurance ?oii-
cies No. 21090 and 2109i including ifs Acciden�al pea+h and Dismem;�ermen� Su:ppi�me7i� b�r ex-
' cluding any group perrnanent life insurance (hereina�te�• caI(cu� "lerm l.i�e 1c�sur�r�cc").
�
i - n�� i�5 r�o;�s .
/�s Used in this Ac�r�emenf;
A. Accoun� ir_��_Period means each succ�edin� �wclve (]2j rnpnfi�e:r+
�)70. . '
�
C.
�
ci�a ar. ;uiv 1
pc �"'.�0511 �'remiums means 1�'l� $Ut71 O�� �'li£ iYlOfli'i+i�/ Ui'�iiilU�llS �?GSC� vy �'i18 �tii�i0��4'.i' i'O 'u`�U2 Cit75.°i'
8{ue Shield�which are due and �xaycrNl� �or �he A.ccountir�;J �'criod irvo�ved �c� H�uii•!� Cvve;•�ae
GY1C,� �Cerm Life (nsurance under i•��e 'iGi(i15 O�f 'f{'1L f�t"i1Ci8S in 'iric GOII�'i�'�CfS Cf1C� �.O�;C�GS CG�iiG�1ECi
"r�remi�ms." Deposii Premiums shaii ae calcula�ed sefxara'reiy ror f-ieal;•n Cove�a,c�e u��d ierrn
Life insurance. � �
Incurred Claims means: '
r
1. The toPal sw� of; (1� alI ciaims paid under �ne bene� ifi provisi�ns �f fhc }-lec��f��� Cove;uge,
and (2) all deafh claims �ia �nder• i-{�e be:nefi� pCOViSi0ii5 Oi ine icrm Li;e ir�sviance, plus
2. �'hc> tofal amount of c'lciir��s esS�imate'c; by 3iue CP`/jJ-81ue Shia;d, ir� accorda7ce wi;n •�4�eir
t10f'fYlp) uccounting practices as s,�ci�ied under "Genec�l .Provisions," 'i0 �J� incur:"�� i7Uj'
unpaid a� the end of such AccounYing Aerio�,� mirtus
3. 7he corresponding es�imate appearir►� in i•he Ias� previous exp�:rience stafiem�r��, �lus
�
� ,� , .
4. S7�0.00 for each �1,0OO.OQ af Group �.i;c Ir�suranca wnich is ex.er�racc: uncier Arficle
Vi or �he Term LiFe Insuranc� cJuring sucn Accaunfing Peri�d, mir��s �
5. �750.00 for each �1,000.00 of Group Life insurr�nce �or which ex'rended bcnefifs �er-
minate during such Accouni�ing Period undc-r A�-i�icle Vf or the Tc�rr, Lire insurance.
D. Administrafiiori Charge means fihe amoun� requir•ed by E3iue Cross-k31ue Si�ieid cluriny an Ac-
counfing Period for t-ho expenses o� adminisfering �he Hec,l'rh Covei�ge anc# 7errn Life lnsurance,
which is an amount equaf t-o i-he sum oi:
l. 709% of Hea(th Deposi% Premiun�s for fhe firsf Accou�nfing �e�iod and 7.9% ai� 4-;eufit'n
Deposit Premiums for eacli Accaun�ing Period rhereaf�er, plus
2. 7,9% or•Term Life Insurance Deposif Premiums i=or the first ��ccour,�i:�g °eriod and %.5�/0
of lerm Life Insurance Deposifi !'remiurns for each Accounfing Period �hereai�eti•. -
' provided, however, fhe'amouni� of Adminisfra�ion Charre �or Heu1�h Cove;•age and Terr� Z:Fe
Insurancc shall be incrcased by fhe an�oun'r of any orcm'surn �`axes �erea�i•cr irn�sed by Jawrul
au��-�orifiy, Gver and above i-hose,presenhly app(icabfe. ,
� i! - CONSfDERA7iON; S�T�'LEMEN"!"S
A. E3iue Cross-Blue Shield__wiil_�urnisli_Yhe Employ_era_r��r� wirl�in r�irei�y�0��s p;=e;_f�e e�
s��acl�/�ccaun.fing Period, de�aiiing De�si� Prerniurns, lr,c�rrcd Claims, cnd Adminisi-ra�ion
Charge �:or such Accounting Perioci surp(us; if the reverse is frue, t��e dir�e�ence snall be con-
siderea the Accounting Period def►cif.
ti. l�F i�i�e repor� reffecfs fhai� i`he sum of De:posif Prcmiums for (-Ic;afth Cov�raae ard Te,m Li�� In-
surance exceeds (ncur'red Claims ana Administra;ion Charce compine�, rne difrerence snaf! be
considerec! the Accaunting Period surplus; i�' �n� reverse is �rue, 7he dif�erence s�ali �ae con-
sidered the Accoun� ing Period de�icji-.
C. The Accounting 1'eriod surplus or deficii, as ti-�e case m�y a�, sncl I ue cornbinec� wi'rh any s;anding
surn(us or def�ici� �rom prior AcGouGi�jz�g Periods. Tre �ic;ure so cleveiooed snc�i I�� lef�j ssanding
i�o be combinecl as proviaed abo,vo �in� ��su�-e Accoun�ing Pericds; such excess shall be a;�p(ied
toward increasing benefiS�s or reducsng premium rr.s�es rar 'rize succceding Accovn;ii:g �eriou�s or
it� no electioi-� is made by i-he Cmployer, be (e�r` s;anding i•o be cornbineu a; provid�.ci abovE i�
fi�ui�ure Accouni-ing Periods. ,
� .
J
D. On i`errnir�ation o� flie Neal�l� Caverag� anu lerm LiSe ii;su;ar,ce, i�he ; i�-,e in;erveninc� berween
the enci of thc� last,previous Aeeoun'ring Pei•icd a�d i•i�e ;er-mi;�ai�ioi� dc;;e si�ail, r�gard�ess of
i-he number of monhhs involved, be consiuered an �'�ccour��in� f'eriod c;nd ten�ai-ive se��►emeni�s
effeci-ed in accordanee wii-!� fhe provisions o� �hc �o�c:��f�;n� �-arac;�c,r,}�, of �{�is Sec�io�� ll. A�
reasonable infervals �hereaffer Biuc Cross--6lue Siliela will z'efund to fine Employer �a��tions of
the then exis�`ing surplus, if any, whicn a're noi• corsid:.��ev by t�Iue Cross-3i�e Shie{d i-o b�
reasonably necessary to cover the remaining clairrs licai{i�y, i inal re�unu o� aii rerr,aining
surplus and reserves, i� any, not necessary ��o cover a��y remuini��g c(crinu iiaailii�� wi11 be rrx�de
i�weni-y-four (24) rnonths uFt�er i�he end o� r`he lasf Accauni�ing Perioc�; piovidt.-i, nowevei-, if i-h�;-e
is a standing deficit on such daYe, fihe Emp(ayer wiii rc�und t�o Blue C�-oss-[3fue S`r�ield i-he les�er
o{' (a) such st�anding deficif or (b) the amount of r�funds, if' any, previously made uncler i���e
i`EnS-ativc settfement of i�his Agreement.
p
.. . r.�. . ,_�.,� �
I�i -- G�N�RAL �ROVISiUNS '
�
%�. l�115 Agr2ern�z�t does no� C7��er t}�e con��uc� CY1G �:Ai;C.�/ �1'OV15(Ot1S i'C jG1'CItQ� 1'hG SCi�i �� Gi
���(�Si'C� Yie(1'1iUfi'1 fQi@S� �JU�'� f01"�C,crificai�ion, .if �eeu�a� li is hereaf QEiGiQi �G ;4 GG i�iG
understandir,g and infient of fine parties f�ha� premium ra;e adjusi�rr,ai�ts v�iiii be calcu(afcd
wif•h �he design tl�a� �eposi't Prerniums wiil ap;�roxin,r�e .�h� iina( cc�;sid�r�ti�r�.
B. . Bfue Cross und Slue Shield have a reciprocal ag;ee;r;ent under wf�ic�� �f-�cy vri!( aliecai�e
settf�meni`s os provided tor in Seciion Ei he�eo;, c�r�a ;l�ey agrc�; ��ha� r'r;e Err���;afershall
have no responsibility f�r or inr�res� in such alloca�ian.
�
. C. �' if1�C C1pi� Qi @X@CU.il6t1 {"�4t�0�, fh2 nc�rmal acccut;� ing �YGC� IC@ G� ClU4 l_.;'GSS-'�iUG �iitG;CU
� . ,
ICl GS�1(1'1Giin; ciaims incurr�ci bu� ur��rid Ci:JPlilu C� %-�CCOU{'1i111� I�c'i'1�>C 15 '� CUit1,:�iC1G'fi0;1 Oi
'i�1@ �O��OVJI7'� j: �i) filU�ilr)iy Ti1G ���J.?5li' (�i�fl1{U�+i rUl' i(18 Ac.cour�fiif�;y I�el'l���� f?iVOiV@Ct ;C� i'i��
� N�ajor N�edical Suppiem�nt Ly tiG°r4, �fus (2) rnu!'riply ;�,e 7e;.osii� ��rer-�iurn r"c; ;�he l�r.�o�r„in,
Period involvea for ti�e Hea(�;1� Covcra�;�s, exciuciin� t��ir suppl�:men'rs, by one ar�c o;��--'r�aii
per ceni (i-Zf2°�o), plus (3) �he to�ul �� al( cicims i��currE� ur�uer �rp �are;ii� a;ovis;cns oi�
;•}�,� y-{eall�n Cove��ac�� (excluding`ifs Major Mec�ieal Su��rcmc�nf} duri��c; rh� Ac�oun; i�;g �eriod
invoived and paid �vi�iiin sixiy (60) a`ays follow;r,g ;r� e�i:� of such'/�ccou��ir,, �'ersod, pSus
(5) t�i,P ro,a) of aIl death claims 7e�ding p�7ymen� or �aid wir•l�in r�ine�y (90) days foif�wing
i}��: �n� o� ti�e Accouni�ir�g Period involved �'or whic;� a i:abiii�y ror �er�efi;s is or cauid b�
incurred during such Accoun�`ing Period, ;�lus t5) �ermin�71 r��a;emi;y �'eserve �r�ua4 �o �5°io
of ma�ernity claims paid duri�g fhe Accoun�ing Periad invo(ved. •
7his forniula is designed to produce a reliable esi`ima',•e; ;�erefore, �l�e resulr� obrair�ed is
subJec�.�o modification for known claim liabili;ies. �
Blue Cross-Glue Shiele� reserves �he r.ighi� ;o refine Gnci/��• revise i-nei; norrnai accouniii��
practic� in accor:lanca with sustuined exp�;rience ut.�on ;urnislzing fo �he Employer a s�a;�e-
men'r of such change. ,
D. ►his rei-ention agreemen� replaces Gny p; ior re�`e��fiio7 c��•eernent wha;soevcr befwee;� i-;�e
pari ies herc:i'o a�d all s�ch ac�re�men�ts ar4 iermirared a�u' sup,:�(erne;i��ci on tnc e�reci ive
��
date hereof. Any si•anding sy'rp,l,us, in'addifiort i'o ail rescrves cxis'rinng on �he e�iecr;ve
u�a�e hereo�, shalS be carried forwara as a crecli� to oe corrained ai� ihe cnd o� �he �i�s�
�/accountiny Period �as�provided herein. .
E. 7hi� Agreemen'r may be ferminai�ed czt i-I�e end o� a�;y Accour„i;�c,� Pe�•iod �ursuar}� ',•u wi•i',•;en
, noi-ice giveci by any p�ity i•o the a�h�ers no� less t�ar� i�i�-,�iy (90) ciuys ir� advc,�,ce i�iereoi .,
, Up�n such fermina;ior�, sei;lement for ���a� final Acc�uc�t�inc� ?erioU sna�{'ae efLec;e� i�;
accordance with the provisions o� Sec� ion d! hereo� . � .
,r
Wifiness our hands rhis�'� day of�`__��.�,�r.�;=�;L.. �;9 J'U
Far Group Hospita) Service, Incr and �
• ;
"`""`- , �;�
Group Life E� H�a1�h (nsur�ance Comp7ny ��,;h1� �,� ,�'���,;.^«,.�;::,,�,������,
� I i�le: / % `�: 1•�' Presidcn� ,.• '`�
'• ; r �/ �, ,�/ �
For City of Fort Worth � • . l /;,�,! ,.�� �';r,r �. ;' ,:; ;: ,
_, ,-
� �ii•Ie:
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6u��uno��y p.�i�.� ae�.} ao�} £Lbl �L£ �aanua� °.} �L61 'L �In� wo.�� :poiaad 6u�.}uno��y
puo�as a�.} .�o� ZL6(. '0� aunr °� LLbI �L �In� woa� :poi.�ad �ui.�uno��y .�s.�i�. ay.� .tof
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l9Li'I'/1. �a':�) �3NOHd3'13„t, . . . . . � � . � 1Ft�Ul53tl� ��E31' �dViVN�t1V3���.'i-WO �� �
. . . . . . _ .. �^�'" . .
F,., 1
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Mro f:odger N,. Line
June 28, 1972
Page Twa
This formula is designed to produce a reliable esfiimate; therefore, the result obtained
is subjecT to modification for known claim liabilities,
Blue Cross-Blue $hie{d reserves fhe cight to refine and�ar revise their normal accounting
practice in accordance with sustained experience upon furnishing to fhe Employer a
stai-emeni� of such change,
if the above adequately refiects your understanding of the Aenendmenfs to be made to the
Experience Rating Agi-eement, please sign in 1-he spc�ce provided for below, retaining the
ct��y f�r y�c�=..t:- i�!es Grd fU�-��vas°�irrc� i��e origina� bacl: ro uso
Sincerely,
' ! �L�%"� ,/, r:e'_r_� CGC-'�t=UiJc � �� , .
� l ' �`
Tom l0 6eauchamp, Jr.
President
TLB:bks
ACCEPTED:
. �
�� � � j ,
�
b' j � =_' L��� L'�"\
Cifiy of Fort Worth
Date: i �`��_ �� /` �' �
!
-
COMPARISON OF BENEFITS
FOR
CITY OF FORT WORTH
BASIC COVERAGE
Bl.ue Cross for Payments to Hospital
ROOM AZLOWANCE
NUMBER OF DAYS
INTENSIVE CARE AND
CARDIAC UNITS
HOSPITAL SERVICES -
Such As :
Drugs and Medicines
Operating�Cysto Room
Anesthesia Service and Materials
X-Ray Examinations
X-Ray Therapy
Laboratory Examinations
Surgical Dressings
P?.aster Casts
Oxygen and Oxygen Therapy
Basal Metabolism Tests
Electrocardiograms
Physiotherapy
Hydrotherapy
Transfusion Service
C_-oss-Matching (blood)
Electroencephalograms
Electro-Shock
Braces (specail equipment)
Radium 'Therapy
MATERNITY BENEFITS
EMERGENCY ROOM TREATMENT
Bl.ue Shield for Payments to Doctors
PRESENT PLAN
$1s
$300 maximum per
calendar year
$18
$300 maximum per
calendar year
(including room
benefit)
$7_00
Covered under $300
maximum allowance
per year
PROPOSED PLAN
$Zo
365
Paid in Full for
365 days
Paid In Full for
365 days (except
blood & plasma
which is covered
under Major Medical
Same as any other
admission
Within 72 hours of
accident, hospital
charges Paid In Full.
Hospital charges Paid
In Full on day of out-
patient minor surgery
SURGICAL SCHEDULE No basic allowance $350 maximum on a
scheduled basis
.
COMPARISON OF BENEFITS
Page 2
BASIC COVERAGE
ANESTHESIA
OBSTETRICAL BENEFIT
DOCTOR'S VISITS TO
HOSPITAL
ACCIDENTAL INJURY
SUPPLEMENT
MAJOR MEDICAL:
Deductible
Room Maximum
Maximum Benefit
PRESENT PLAN
No basic allowance
None (if $1_00 allow-
ance is paid to
Hospital)
PROPOSED PLAN
If rendered by a
Medical Doctor -
20% of amount paid
operating surgeon.
If rendered by a
Hospital Ixnployee,
Paid In Full
$80 Normal Delivery
$165 Caesarean Section
None $5 per day beginning
with the lst day of
Hospital confinement
for 30 days
$25 payable to
Physician within
72 hours of accident
$50 per calendar
year
$18
$150 benefit payable
in addition to Blue
Cross-Blue Shield
benefits for such
expenses as:
Ambulance
Additional Hospital
charges
Physician charges
Prescription drugs
$]_00 per 365 day
period heginning
with date of 1st
medical service
$40
$5000 $5000 per benefit
period
$10,000 lifetime
$12.50 maximum per
week out-patient
psychiatric care.
Also provides benefits
for:
Additional Doctors
charges
Ambulance (to and from
hospital when admit-
ted as a bed patient)
Out-patient Prescript-
ion and drugs
COMPARISON OF BENEFITS
Page 3
To compare your present deductions with the new deductions, find the amount you are
presently paying and read across to the new deduction column,
PR.ESENT DEDUCTIONS
$ .59
.99
.1. 34
1.74
2.13
4.89
5.28
5.68
6.04
6.43
6.83
8.32
8.71
9.11
NEW DEDUCTIONS
$ .59
.99
1.74
2.14
2.53
6.38
6.77
7.17
7.65
8.04
8.44
8.53
8.92
9.32
CLASSIFICATION Your cost Bi-Weekly - Hospitalization & Life Insurance
Class I Class II Class III
Employee 1.74 2.14 2.53
Employee & Spouse 7.65 8.04 8.44
Employee, Spouse & Children 8.53 8.92 9.32
Employee & Children 6.38 6.77 7.17
LIFE INSURANCE COVERAGE IS FOR THE EMPLOYEE ONLY
Classification (Annual Salary) Amt. Life Ins.
Class I - Less Than $3,000 $1,000
Class II - $3,000 to $6,000 $3,000
Class III - $6,G�'00 and over $5,000
Amt. Accidental D & D
$1,000
$3,000
$5,000
QUESTIONS AND ANSWERS ABOUT YOUR NEW HOSPITALIZATION PROGRAM
1) Question: How much will my payroll deduction increase each pay day to pay for
the increased benefit?
Answer: On the attached sheet, locate your present deduction and compare it
with the new deduction listed, which will be deducted for the first times on
June 5, and June 19, 1970.
2) question: When will the new benefits be effective?
Answer: July 1, 1970.
3) Question: If I am in the hospital when the new benefits become effective, will
the new plan or the old plan pay for that hospital confinement?
Answer: If you are admitted to the hospital before 12:00 midnight June 30, your
old benefits will be in effect for consideration of all charges incurred during
that hospital confinement. I� admitted after 12:00 midnight June 30, your new
plan will provide benefits for that confinement.
4) Question: If I, or one of my dependents, have used up the entire $5,000 maximum
benefit, what benefits do I have under the new program?
Answer: Everyone enrolled under the new program will have full benefits, regardless
of prior utilization.
5) Question: If I have satisfied my $50.00 deductib3e for 1970, how does this affect
my new coverage?
Answer: In order to provide the payment of new benefits on a11 existing members,
without regard to waiting periods or prior utilization, it is necessary to have
everyone begin a major medical benefit period with a new deductible. However,
your new benefit period will begin with the date of the earliest medical charges
incurred after 7-1-70 and continue for 365 days, before any other deductible will
be required, You will be pleased to know that the new plan pays many basic benefits
without any deductible required,
Page 2
6) question: What benefits for psychiatric care are available under the new plan?
Answer: The basic benefits for in-hospital psychiatric care are the same as any
other admission when admitted to a Blue Cross member hospital. A maximum of
$12.50 per week for out-patient psychiatric care is eligible for consideration
under Ma.jor Medical.
7) Question: What benefits are available for dental surgery?
Answer; Benefits for dental care necessitated by an accidental injury are pro-
vided by the Accidental Injury Supplement and Ma.jor Medical. Basic Blue Cross
benefits are payable to the hospital if you are admitted as a bed patient for
dental surgery or impacted wisdom teeth.
8) Question: What benefits are available for treatment by a podiatrist?
Answer: Basic B?ue Shield benefits will be payable to a Doctor of Podiatry for
any service for which a payment would have been made to an M.D. or D.O. A service
of a Doctor of Podiatrq shaYl be considered by Major Medical only if a benefit is
paid for such service under the Basic Blue Shield.
9) Question: If I am a male employee and my wife is now pregnant, what benefits will
be paid for delivery?
Answer; If you and your wife are both covered under the same Blue Cross contract
(employee & spouse or employee and family contract), and have satisfied the 9 month
waiting period as of date of delivery, old benefits will be paid if delivery is before
7-1-70. However, if your wife enters the hospital on or after July 1, for delivery,
the new benefits will be paid,
10) Question: If I am a female employee, and am now pregnant, what benefits may I
receive?
Answer: Your old program provides matexnity benefits for female employees who
do not have their husbands enrolled with them. Maternity benefits will be provided
Page 3
10) Answer: under the new plan only for those who become pregnant while the o1d
plan was in effect. If the female employee is admitted to the hospital prior to
7-1-70, the old benefits wi11 be paid. If she is admitted after 12:00 midnight,
June 30, the new benefits will be paid.
11) Question: I am not now enrolled in the plan, and my wife (or I if a female
employee) is now pregnant, Will we receive maternity benefits if we enroll
effective July 1, 1970?
Answer: No. You and your spouse must be enrolled for a continuous 9 month
period to delivery in order to receive maternity benefits,
12) estion: If I am now enrolled on the plan, do I need to complete another
application card?
Answer: No. If you are now enrolled, your benefits will automatically change
7-1-70.
13) Question: If I am not enrolled, when and how may I do so?
Answer; Between May 13 and May 28, a11 employees wi Il be contacted and given the
the opportunity to enroll.
14) Question: If I, or one of mq dependents, have been previously rejected for
coverage due to a health condition, may I enroll for the new plan?
Answer: Yes, you may enroll for full benefits of the new p1an, regardless of
health conditions.
15) Question: If I do not wish to enroll during the above period, when will I have
another opportunity to enroll?
Answer: Your next opportunity to enroll with be during the month of May, 1971,
for an effective date of July 1, 1971.
16) Question: Gyhat if I, or one of my dependents have cancelled our coverage?
Answer: You may re-enroll yourself and include your dependents for coverage
effective July 1. However, you must enroll prior to May 28 for coverage to be
effective 7-1-70.
Page 4
17) Question: How do I enroll my dependents?
Answer: A dependent addition form will be available to you at each enrollment
meeting. Please request one if you wish to add a dependent. I€ you add a
dependent a new payroll deduction card needs to be signed by you.
18) estion: Under the new plan, to �ohat age may I carry my children?
Answer: Your children may be carried until they become 25 years old or marry.
Student classification, residency requirements, and financial dependency are no
longer required.
19) estion: Who may be considered eligible dependents for coverage under my policy?
Answer: Your spouse and any unmarried children under age 25 for whom you have
applied for coverage.
20) uestion: If I have Blue Cross through my spouse's place of employment, am I
eligible to enroll in this program also? If so, will both plans pay?
Answer: You may be covered by two Blue Cross Plans. Both plans will pay benefits
for eligible medical expenses, However, the total payment received wi11 not
exceed the eligible medical charges.
21) uestion: Do any of these changes affect our group life insurance program?
A�nswer: The changes to be made effective July l, 1970, affect your hospitalization
benefits onlq.
22) question: Ma.y I enroll for hospitalization, but not life insurance.
Answer: No
23) uestion: May I enroll for life insurance, but not hospitalization?
Answer: Yes, if you are a military retiree are if you are covered by Blue Cross
through your spouse's place of employment.
�
�i�� ��' ���� ���°��a., `����
.�����r ��,� c����.��lC c���,m�uc���c��t���
�r
DATE
6/3/68
NUMBERCE SUBJECT: GYOUP Hospitalization Coverage PAC'i
G-1242 for City of Fort Worth Empioyees � lof —
�����
The anniversary date of the contract with the Group Insurance Carrier of
the City of Fort Worth, Blue Cross-Blue Shield of Te�as, is July l.
Revisions normally become effective on that date. Last year, due to the
claims experience for the preceding two years, an adjustment in rates was
made on the anniversary date. The�Carrier has recently advised the City
that the present rates may be continued for the next policy year. The
present rate structure will permit in addition to present benefits the
increase of the present $15.00 per day room allowance to $18.00, and the
removal of the 90 day accumulation clause on the $50.00 deductible to
allow the accumulation on an annual basis. The Insurance Study Committee,
appointed by the City Manager and composed of representatives from various
departments, has reviewed the proposal of the Insurance Company, and has
considered cost figures on other additional benefits to be added to the
Insurance program. The Committee has recommended to the City Manager
that no changes involving rate increases be initiated at this time, and
that the improved benefits available without rate changes be accepted.
The City Manager concurs in this recommendation.
It is recommended that the City Council accept the increase in the daily
room allowance from $15.00 to $18.00 per day and the removal of the 90
day accumulation clause on the $50.00 deductible, without any increase
in existing rates, and that the contract be amended accordingly.
HDM : f k
SUBMITTED BY:
; �,�'�` ���
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CITY MANAGER
�1 BY COUNCIL:
APPROVED ❑ OTHER (DESCRIBE)
PROCESSED B
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CITY SECRETARY
DATE
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