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J . HOSPITAL ADMISSION means the period between the time of a participant's entry into a member or non-member hospital as a bed-patient and the time of discontinuance of hospital care or discharge by the physician, whichever first occurs. The day of en- try, but not the day of discharge or departure, shall be considered in determining the length of a hospital admission. K. PERIOD OF HOSPITAL CONFINEMENT means the combination of any number of hos- pital admissions of a participant, excluding admissions for maternity care, until there is an interval of at least ninety (90) days between any two consecutive admissions. L. CARE means the services furnished by a hospital, at the request of the physician, and used by the patient while in the hospital, which services are necessary and consistent with the illness or injury for which the patient is being treated. The term does not in- clude any services furnished by a hospital to ambulatory patients on a self-care basis, or an arrangement contemplating provision of only minimal services with meals to be taken outside the hospital bedroom. AIM M. ADMISSION FOR MEDICAL CARE means a non-obstetrical hospital admission during which no surgical procedure is performed, or only minor surgical procedures are per- formed, not incidental to the primary condition for which the patient is hospitalized. N . ADMISSION FOR SURGICAL CARE means a hospital admission during which one or more surgical procedures are performed in relation to the primary condition for which the patient is hospitalized. O . ADMISSION FOR MATERNITY CARE means a hospital admission for pregnancy or complications of pregnancy. P. OUT-PATIENT CARE means hospital care rendered a participant at any time other than during a hospital admission. O. CONTRACT MONTH means each succeeding monthly period, beginning on the con- AMENDED. ) tract date. SU Art X R. CONTRACT ANNIVERSARY means the month, day and year specified in the applica- Sec. L tion and the corresponding date in each year thereafter for as long as the contract is in force. S. SCHEDULE means the Schedule of Specifications appearing in the Employer's applica- tion herefor, or the latest of any revised schedules submitted by the Employer and ac- cepted by the Plan to replace one previously effective. T. INTENSIVE CARE UNIT means afacility of a hospital, apart from patients' bedrooms, operating room, or recovery room, which is used for patients whose conditions require unusual nursing care, beyond the general nursing services provided by the hospital . It does not include the services of private special-duty nurses. U . PRE-EXISTING CONDITION means any abnormal physical or mental condition, whether active or inactive, existing before the patient became a participant hereunder, including all deformities, ailments or prior injuries which may thereafter become ag- gravated by subsequent injury or disease. 59BW-Z09B _ .-. �.l 4 . _ _ _ - _- _ 4.. 1Y.��z�-✓r� I � ' •pa.}�iwqns si uo��a���dda a�� aa��p s�(ap (0£� �(�a!�{� �sba� �a san��o ��i�nn �(absaaniuua �aaa�uo� 6uipaa��ns a�+ uo ani+�a�}a auao�aq ��a�s a6paano� a�� 'a�qi6i�a sauaoaaq �updi�i�aod a�.4 a.�pp a�� aa��o s�Cap (pE) �C�ai�.� ua�+ aaoua pa�.�i�uqns si uo��a���dda a�� .�uana �(ua ui }I �E •��aiq a�.� �o a.�pp a�� �o sa ani��a}�a a�uo�aq ��a�s a6aaano� a�.� 'p�i�{� uaoq �nau o�o a6qaanoa ao�} uo��a���ddb ��ns �}o asp� a�.� ui '+b�.� +da� _xa'pa.��ivaqns si uo�+a���dda a�¢ �a�� a�pp a�� �ui�no��o� a�apanp uanivaaad puo�as a�� uoani¢�a}}a auaoaaq ��o�s a6aaano� a�� '�(�i�iqi�i�a }oa+ap a�� �uinno��o� s�(ap (p�� �C�ai�� �sai� a�+ ui��i�n .�nq a�.ap .��pa.�uo� a�� aa.��n pa+�ivaqns si uoi}b�i�dda a�� �i pua 'a�pp +�oa�uo� a�� aa��a ao uo 'aao�aq a�qi6i�a sawo�aq .�uadi�i+aod a�+ }! •z • a.�ap ��oa�uo� a�� uo ani.��a��a auao�aq � �p�s a�baano� a�� 'o�aaa�� aoiad pa��i u.iqns si uo��a���dda a�.� �i pua'a.�pp .��aa�uo� a�.� aao�aq a�qi6i�a si �uqdi�i�aad a�.� �� ' L :s�no��o� sa ani��a��a auao�aq ��a�{s a6aaano� �uo�+p���dda a�� �o a�ua; -da��a o� .}�alqns 'uodnaaa�{� 'ua�d a�+ o+ �i 6ui��iu�qns s,aa�Co�du�3 a�� uodn pup uald a�{� �(q panoadda uaao� a uo ao�aaa�.� UOI.�I»IICiCIp GUI�t�LU s�aa�(o�dwa a�� uodn �ua6ui� _uo� aq ��a�s auapuadap paaosuods ao +uapuadap 'aa�(o�dwa a�qi6i�a ��oa }o a�aaano� •� •s�uapuadap paaosuods pua s�uapuadap a�qi6i�a si� }o a�naano� o� �uapa�aad uoi+ipuo� q aq ��a�s aa�(o�duaa a�� }o a�aaano� •8 •uoi�isinb�a ��ns �o a�ap a�� uo a�qi6i�a auao�aq ��p�s a6aaano� s,aa�(o�duaa a�.} �o a�ap ani.��a�}a a�� aa��a di�supipaan6 ao uoi�dopp '��aiq 'a6aiaaaua �Cq paainb�p saaquaaw �C�ivaa� •s�uapuadap paaosuods pup s+uapuadap sasaaquaaua �(�ivaa} si� pua }�asuai� ao� ao ��asuai� ao� aapunaaa� a�aaano� ao� �(�dda o¢ a�qi6i�a auao�aq 'pai}!�ads uiaaa�� a�inaas �o ��6ua� a�} }o uoi�a�duao� uodn '��a�s ��suoi�a�n6a� �(�i�iq -!�'13�� aapun ao�}aaa� uoi�o�i�ddp a�� ui pacjia�sap suoi�b�i�issp�� a�� �o aa�(o�duaa �uy •y S31b'4 3/�11�3��3 �3Jb'�3/�O� �O� J.lIl181J113 - II 31�11�`d � � S901W-0698 �� __. ... .._ . .. _ _ . . . ._�_.. . :�' .. ___�. - __ _-' __' — - �� _ _ l _. • a�ub{+iwaa dnoa6 a�� �o +aod o so piad uaaq �ou sa� u�nivaaad p uao�M ao� aa�(o�du�3 �Cub �o a6aaano� a�� pua+xa o+ sa os pana�s -uo� aq +ou ��p�s pua 'wnivaaad �(���uoua �p�o; a�+ o+ �C�uo a�qp�i�ddb si poiaad a�ba6 a�� }o a�ub�no��o a�l •poiaad a�aa6 a�� 6uianp a�ao� ui sa�n +�aa�uo� a�� auai� a�+ ao� wni�.uaad a�pa oad a�o �ua�u�(ad ao� uo�d a�� o} a�qoi� aq ��a�s aa�(o�d�.u3 a�� 'poiaad a�pa6 a�� }o pua a�+ �a ao 6uianp sa.�auiwaa.} .��oa�uo� a�{ }� •y uoi.{�aS �II/� al�!�ab' �o suoisinoad a�� ��i�n a�uapao��a ui uoi�ouiwaa� �o a�op aai�apa ��ns }o a�i�ou ua��iaM up�d a�� uani6 anp� ��a�s aa�(o�dw3 a�� papinoad (piad uaaq ana� suaniu�aad ��i�M ao� poiaad a�� }o pua a�� o� aoiad �ou si ��i��n� a�op aai�apa ua �a a�puivaaa� ��a�s ��qa�uo� a�+ �o�} �da�xa 'poiaad a�ba6 ��ns �o pua a�� +a a�puiwaa� ��a�s ��aa�uo� si�� 'poiaad a�ba6a�� ui�+in� pipd�ou si i.unii.uaad �Cup �� •�sai� ay.} �da�xa wniuiaad ��ba �o �ua�.u�(od a�� ao� pan�oll° aq II"�Is 'a6aa�� �saaa}ui �no�}inn 's�(ap auo_�(.�ai�� �o poiaad a�qa6 y J •pauio�qo sn�� suoisua�xa a�� 6ui��a}o� pup 'uoi�p�i�issa�� �p�� ao� a�qa a�+ �(q a�qa�i�dda ua�� sa�oa }o a�npa��s a�{ ui uoi}p�i�issa�� ��ba ao� paaano� saa�(o�duaa �o aaqwnu at�� 6ui�(�di.��nw �(q pauiwaa�ap aq ��b�s aapunaaa� pibd aq o� u.iniuiaad a�l •Q •aapunaaa� a6paano� ao} a�qi6i�a aq o.� pasoa� aa�(o�duaa a�� ��i��n 6uianp ��uoua ��pa�uo� a�� �o pua a�} woa� papun�aa pub pa}p�n��p� aq ��o�s sa.}bp anp u�nivaaad ubt�� aa��o �b sa�puiwaa� aapunaaat� a6paano� aso�n� saa�Co�dwa ao} si.uniwaad pauaoaun •�uno�sip �not�+iM �nq '.{�a�a �aw aa�Co�d�.u3 a�� SfJ SISt�CI Ipf1UUl� a0 �Iqf1UUq—ILU2S '�(�aa}aanb '����uow q uo piad aq �tpua suanivaaad •� •��pa+uo� si�.� aapun UOI{t��l}ISSpI� aa�.�o ao dnoa6-qns �(up ui��iM saa�(o�duaa ��p o+ a�qa�i�ddo �(�uaao�}iun apbw aq ��a�s a6ub�� ��ns �(ub pua 'aapunaaa� paaan�ui uaip�� �tuo �o �(�a�os {uno��b uo uoi�o�i�issa�5 6ui�aa a�� ui appt,u aq ��a�s a6ub����ns oN •apa�( �uipaa��ns a�� o�a�qa�i�ddr� sb'�(aas -aaniuup ��aa�uo� �(ua uo sa�pa wnivaaad a�� a6ua�� o.� ��6ia a�� sanaasaa uo�d a�� �nq 'ua�d a�� �o s6uivaaa a�� ui aaa�s �ou saop �� •a�qpssasso-uou aq ��a�s ��pa�uo� si�l • uanivaaad �(���uoui �p+o.� r� �uasaadaa �ou saop ��i�nn ua�d a�� �(q pa�da��a aq ��a�s �uau��Cad oN •a�ubnpa ui a�qp�(bd '��ba�uo� si�� �o a�uanui�uo� a�} 6uianp 'aab swnivaaad .}uanbasqns 'a�ap ��pa}uo� a�� uo anp si uaniu.iaad �sai� at�� :suoisinoad 6uinno��o� a�� ��i�n a�ubpao��p ui 'sbxal �SpIIpQ ui ub�d a�} �}o a�i��0 awoH a�� �a aa�Co�dua3 a�� �(q su�nivaaad a�� }o �uau��bd uodn �ua6ui�uo� aq ��a�s aapunaaa� a6paano� a�.� �o a�upnui�uo� pup 'uoi}b� -��dda at�� ui ��su�niu�aad�� aapun un�ot�s sb aq ��at�s ani}�a��a �(Ila!}iui sa�aa u�niwaad a�l SWf11W��d - III 31J11�'d : � 994W-4098 �(aa6ans aouiw �uai�od-¢no }o a�up�sui uy • � ao '�(anlui �a�uapi��o ua �o aaa� �uai�ad-�no • q ao '�(�ddo ��aa� -uo� si�+ �os+i�auaq at�� ��i��no� �oaaa�+ uoi}aod a�� ao'uoissiwpb �a�idso� y •n :�0 6ui�sisuo� '��aso�„ ��ba ui �a�idso� a�(q pa�sivan� sa�inaas a�} o} uoi�a�aa ui apaw aq ��b�s 3 uoi��as si�+ aapun s�i�auaq }o uoi�auivaaa�a4 •Z • aapunaaa� a6aaano� si� �o a�bp ani��a��a a�{� ua�� aai �apa si a6paano� aa��o a�+ aapun uo�+ad����aad s,�uai�ad a�.� �o a.}ap ani��a��}a a�l 'q '}sixa .�ou op suoi�ipuo� aso�� �i ao '��aa�uo� si�.� aapun uosaad a�puaa} a�o +uapuadap puo a6aaano� aa��o a�� aapun uos �aad a�aw a}o �uapuadap sa ao '��aa�uo� si�� aapun +uapuadap sq pup a6qaa _no� aa��o a�{� aapun paansui �(aouaiad ao aa�Co�dwa sp pai�issa�� si �uai.�ad a�l • p :pua suoisinoad ��ns sa� �i ua�nn ao 'suoisin _oad uoi�b�i�dnp-uou 6uipuodsaaao� a�p� �ou saop a�paano� aa��o a�{� ua�n� �C�uo 3 uoi+�aS si�� �o suoisinoad a�� �Cq pai�ipoua aq ��a�s .��aa�uo� si�� �o s}i�auaq a�l :3 uoi��as si�� �o suoi.}�asqns �ui _nno��o�} a�; ��i�na�uppao��aui pauiwaa�ap pup �.}in�aaa�� pa+puipaoo�aq ��a�s ��aa�uo� si���os+i}auaq a�� sai�dda a6aaano� aa��o 'aao�aaa�� 'ua�M •s+i}auaq UOI�pZIIp�ICISOI' o� pa�.�i�ua si a� ��i��n aapun '�(�iaoN�no �(ao�n�b�s �(q 6ui�sixa waa6oad �p}uauauaano6 �Cua apn��ui o+ pauaaap aq asi�na�il II"�is uaaa� a�l •sa�inaas pipdaad ao �C.}iuwapui �}o aan�au a�� ui aap s�i�auaq a�� aa��a�nn pua 'aaiaap� aa��o �(uo ao ub�d a�� �(q panssi aa��a�nn '�oaaa� 6uivaaua a�� ui��in�.��a6baano� aa�}o�� paaapisuo� aq ��p�s dnoa6 aa�n� -i�aad a o� uoi+a�aa ao ui di�saaquaaua si� �o an�ain�(q sasuadxa �a�idso� ao�pua �a�ipaua ao} uoi+�a�oad sp�o� �ubdi�i.}apd a�.� �{�it��n aapun �(�i�od ao .��qa�uo� aa��o �(uy •a6aaa _no� aa�.�o �o a�uasqa a�.� uodn �ua6ui�uo� aq ��o�s pai�i�ads uiaaa� s�i}auaq a�� }o �(� _i�iqa�ipnba�� �a�� ua�d a�� pua aa�(o�dua3 a�� �o�ua�ui a�� aq o� paab��ap �(qaaa� si .}I ' 3 • a�qbu6issa +ou aaa aapunaaa� papinoad s�i�}aua8 • Q •a+p�sa s,aa�(o�duaa a�} o� piad aq ��p�{s s�i�auaq ��ns ua�+ 'asnods 6uininans ou si aaa�{.} }! '�ap!�i�auaq sp 'aa�to�duaa a�� }o asnods 6uininans a�� o� piad aq '�+oap si� +p pipdun �i '��a�s 'aa�(o�duaa a�� o� a�qa�(ad 'aapunaaa� s�i�auaq �Cu�.� •� °��pa.�uo� si� aapun }uodi�i.�aad �(uo o� paaapuaa aaa� �o .�uno��p uo aa�(o�dwa a�� o� up�d a�� �}o �(.�i�iqisuodsaa ��p �o a6aa��sip Iln� a�n�i}suo� ��a�s '��a�a �(pua uo�d a�� sa 'aa�o�duia a�.� o+ aoaap� a�� 6ui�(�ddns �b+idso� a�+ o� ub�d a�� �Cq s{i�auaq }o �uaua�Cbd '9 •n a��i{ay ui pa�ia+ap sa ��a 's�o�idso� aaquaaua-uou �(q pa�sivan� aao� ao� pai}i�ads sa�uanno��o a�� �tad ��i�n pua 's�p�idso� aaquaaua �(q pa�sivan� aaa� ao� pa�si� s�i�auaq a�� apinoad ��iM ua�d a�� 'uiaaa� ��ao� �as suoisn��xa pua 'suoi.�a�ivai� 'suoi+b�i�i�pnb at�� o� +�alqns •y NOIl`d�lld(l4-NON 'S11�3N39 �O 1N3WAb'd - /�I 3lJll�b' 3. When this Section E is applicable, the hospitalization benefits of the other cov- erage shall be deducted, item by item, from the charges for all items of hospital service for which any benefit is provided under Article V hereof, or other coverage, and the Plan will pay the remainder of the charges for such items; provided, how- ever, that in no event shall the provisions of this Section be construed to increase the amount of total benefits which would be payable hereunder in the absence of other coverage. IIMM 4. When benefits are provided by other coverage for certain itemized services in 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. 5. The Plan assumes no obligation to discover the existence of other coverage or the benefits payable under it if discovered, but only to give effect to the provisions of this Section E in accordance with information furnished it by an authoritative source. It shall, however, be entitled to obtain and/or to release such informa- tion as is reasonably necessary to give effect to these provisions, without the con- sent of or notice to any person; and any person claiming benefits hereunder shall, as a condition precedent to his right of recovery, furnish to the Plan full informa- tion 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 coverage, 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 to the issuer or provider of such other coverage any por- tion of the benefits available under this contrdct which the Plan may determine to be due in order to give effect to the intent of this Section 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. 59BW-5098 � � ��.`�+a •poiaad awqs a�.� 6uianp aao� �uisanu �qaaua6 pua 'paaoq 'wooa ao� a�upnno��a aa��o �Cub �o nai� ui papinoad aq ��a�{s �i�auaq si�l • aap� ��ns sania�aa a� ��i�nn 6uianp '�(op ��oa ao� +iun aap� anisua+ui uo ui }uadi��}apd q papin -oad aaa� ao� a�up�no��a .�i}auaq �.unwixpw a�� aq ��o�s (aap� �b�i6ans ao� uoissiwpq uq ao aaa� �a�ipaw ao� uoissiwpq ua �o aso� a�.� ui '8 uwn�o� puq'aap� �t�ivaa.�qw ao� uois -siwpa ua �o asa� a�.� ui 'y uwn�o�) a�npa��s a�� �o � wa�i ui pai�i�ads s.�unowa aNl :aaq� anisua�u � • � •a�npa��s a�� }0 8 uu�n�o� '6 uaa�i ui pai�i�ads �unowa a�qi��npap a�{� o� ��alqns aq (�pys aaa� �p�i6ans ao� suoissivapy •suoissiwpa ��ns ��a ao� pa+�np -ap aq o+ �a�o� uanwixow a�+ aq ��b�s pai�}i�ads �unouab a�{� �(�uau�aad auo o� pa�a�aa uoissiwpb auo uo�� aaow �o asa� a�� ui �a�� �da�xa 'a�npa��s a�� �o y uuan�o� '6 uaa.�i ui pai�i�ads �unowb a�qi��npap a�+ o� ��alqns aq ��a�s aaa� �(�ivaa�aua ao�} suoissivapy • a�npa��s a�� �0 8 uuan�o� 'g i.ua�i ui pai�i�ads �unouaaa�qi+�npap a�� o� ��alqnsaq ��a�saap� �o�ipaua ao� suoissivapy •aaa� �uai�pd-�no ao� a�qo�ianb s�i�auaq a�npaa o� �C�ddo �ou ��a�s sa�qi��npa4 •�uauaaui�uo� �a�idso� }o poiaad a�6uis b ui an��o �(aw L��II�M', SUOISSILUpp }o aaq�.unu a�{� }o ssa�paa6aa ' �a�idso� aaqwau.i a ui uoissiwpb ��aa o� pai�ddq aq ��a�s a�qi��npap a�� 'nno�aq pai�i�ads asi�naa��o so �da� _x3 •a�qp�iana aq asinnaa�{.�o p�nonn ��i�nn �i�auaq �a�o� a�� a�npaa o+ a�paado 'a�qb� -i�dda uat�nn ' ��a�{s a�npa��s a�� }o (, pua g su.ia�i ui pai�i�ads s+unowa a�qi��npap a�j :sa�qi��npa4 ' 8 •�uawaui�uo� �a�idsoy �o poiaad ��aa ao� suoissivapa ��ns Ilp aO� alqpl!pno s�(ap �o aaq�.unu wnwixbu.i a�� �.�ao} s�as ��i��n '8 u�un�o� 'Z u�a}i �(q pauaano6 aap aaa� �a�ia�a�sqo-uou ao� suoissiwpy •/�upu6aad ��aa o� pa�a�aa suoissiwpq ��a ao} a�qa�ibna s�(pp �o aaquanu �unwixpua a�� ��ao� s�as ��i�rn 'y uuan�o� 'Z uaa�i �(q pauaano6 aaa aaa� �(�ivaa�aw ao� suoissivapy ��uad��i�aod a�o aao� �uai�ad paq ao� a�qp�iana aq Ila�s a��i�ay si�� �o suoi��as �ui�no��o� a�� ui pa�ia�ap s�i}auaq a�+ ��i�{n� 6uianp awi� �o spoiaad �unu�ixqua a�� auiwaa}ap ��a�s a�npa��s a�� }o Z u�a�i ui pai�i�ads s�(op �o aaquanu a�l :a�qa�ipny s r�4 �o aaqwnN •y 511�3N38 - n 3l�ll�b' � r D. X-ray Examinations: The maximum benefit for all X-ray examinations made during all admissions for medical care and all admissions for surgical care constituting any one period of hospital con- finement shall be limited to the amount specified in item 5, column B of the schedule. The maximum X-ray examination benefit for all admissions for maternity care in rela- tion to any one pregnancy shall be limited to the amount specified in item 5, column A of the schedule. E . Benefits for Medical Care or Surgical Care in a Member Hospital: Subject to the deduction determined as set forth in Section B, above, and subject to i the limitations, exclusions and all other terms and provisions set forth herein, when any participant receives medical care or surgical care as a bed patient in a member hospital he shall be entitled to benefits as follows: 1 . A daily allowance to apply on the charge for room accommodations, including meals, special diets and general nursing services not exceeding that specified in i item 1 , column B of the schedule, for the period of confinement not exceeding the number of days determined as set forth in Section A, above; and 2 . Intensive care in accordance with the provisions of Section C, above; and 3. X-ray examinations in accordance with the provisions of Section D, above; and 4. All other care in the nature of usual hospital services (except blood and plasma) furnished directly to him as the patient, up to, but not exceeding the amount i specified in the schedule as item 3, column A in the case of all admissions for maternity care related to each pregnancy, and column B for each period of hos- pital confinement in the case of medical or surgical care. The cost of blood and plasma is not provided asa benefit, but the full cost of transfusion services, blood typing, and cross-matching of the blood of the patient and donors is included; i provided, however, the maximum total benefits available for any period of hospital confinement shall not exceed the amount, if any, set forth in item 10, column B of the schedule. i F. Eligibility for Maternity Benefits: i Benefits shall be available for an admission for maternity care only if the patient and her husband have held coverage under this contract, one as employee and the other as dependent, for at least the period of time specified in item 7, column Aof the schedule i immediately preceding the termination of the pregnancy; provided, however, that this requirement will be deemed to have been satisfied upon certification by the attending physician that the pregnancy was terminated earlier than at full term and that full- i term pregnancy would have extended to a date beyond the completion of the waiting period for maternity care. 899W•9098 �� -'� ``. �aa�}paaa�� 6ui�uauau�o� uoissivapp �n�idso� �(ua �o �uno��o uo papinoad aq ��o�s s�i�auaq ou �nq 'uoi�auiwaa� }o a�pp a�� aao�aq 6ui�ua�,uwo� uoissivapo �a�idso� p�o �uno��p uo pa�}i�ua aq asi�naa�.�o p�no�n ay ��i��n o� s�i�auaq �(uo �}o }upd���}aod a aniadap o� a+aaado �ou ��a�s a6baano� �o uoi�puiwaal a6baano� �o uoi�auiwaal }o ��a�}3 • � ° •s�i�auaq +uai�bd _.�no �o uoisinoad a�.� �Cq aauuoua �(ub ui pa�npaa aq aap� .}uai�nd paq ao� a�qp�iana s�i�auaq ay� ��a�s aou 's}i�}auaq �uai}ad-�no ��ns a�npaa o+ pai�ddo aq ��a�s a�qi��npap oN •sisoq �uai�ad-paq a uo paaapuaa uaaq pa� aaa� a�+ }! ��pa�uo� si�{ �o s}i�auaq a�� �o ado�s a�} ui��i�n uaaq anp� p�nonn ��i�nn pa�sivan� sa�inaas f�a ao� a6aa�� s,�p�idso� ay� �o +unouao a�� ui s�i�auaq apinoad ��i�n ua�d a�� '�isin +uai�ad-�no a�� �}o asano� a�� 6uianp pauaao�aad �(aa6ans aouiw ao� ao '�isin �uai�od-�no ay� 6uipa�aad sano� (zL� onn� -�(+ua�as uq�} aaow �ou 6uiaan��o �(anlui �o}uapi��o }o ��nsaa a�� sb �b�idso� aaquaaua-uou a ao �a+idso� aaqu.iaw p�(q pa�sivan� aao� �uai�ad-�no sania�aa +uad��i�aad �(ua ua�M :�p��dsoH aaquaaua-uoN a ao �a�idsoH aaqwaW p ui aao� �uai�ad-.�n� ao} s�i�aua8 •� •a�npa��s a�� �o p� uaa+i ui �.}ao�} +as '�(ua }i '.�i� -auaq wnurixaw a�� a�npaa o� pai�dda aq '.aanan�o�'.�ou ��a�s uoisinoad si�l •�a.�idso� aaquaaw a �(q pa�sivan�} uaaq pb� aaa� auabs a�{+ }i pana��p ana� p�nonn ��i�nn (�(ua �i 'a�qi}�npap a�� �o uoi+a�i�ddp aa+�a)s.�i�auaq �o an�an �q.�o.� a�� }o (o�oSL) �ua� aad ani� -�(.�uanas o.� �anba s�i}auaq o.� pa�.�i.�ua aq ��a�s a� �a�idso�aaquaaua-uou o ui {uai.�od paq a sa aab� �(.�ivaa�aua ao aaa� �a�i6ans ao aaa� �aaipaua ao� pa�.�ivapa si.�undi�i�apd �tuo ua��n 'uiaaa� ��ao�.�as suoisinoadpua suaaa�aa��o ��ppua suoisn��xa'suoi�a�ivai� at�}o.� ,��alqns :�a+idsoH aaqwaua-uoN a ui aaa' .�uai�pd pa8 ao� s.�i�aua8 • H • papinoad .���auaq a�.� aq � �qNs wns aa.�aaa6 ou pua .�unouaq �p�� ua�� �y uwn�o�'pt uaa.�i ui pai�i�ads {unowq a�+ paa�xa p�no�s �t�ubu6aad auo �Cup o� uoi�b�aa ui pauiwaa�ap sn�.� s.�i�auaq ��a �o an�an �p�o� a�.� �i +o�� .�da�xa pub 'a�np -a��s a�.� �}o y u�.un�o� '� i.ua�i ui pai�i�ads .�unowa a�.� aq ��a�s a�ua�no��a �.uooa �(�inp a�qp�i�dda ay.� �o�.� �da�xa 'anoqa '3 uoi��as �o s�dqa6aaod paaaqwnu a�.� ui pa�ip.� -ap sq s�i�auaq o.� pa�.�i.�ua aq ��a�s a�s �p�idso� aaquaaw a ui aap� �(.�ivaa.�aw ao} pa�+iw -pq si �uad��i�aqd a ua�nn 'uiaaa� ��ao� �as suoisinoad pup swaa� aa��o ��o pup'suoisn�� -xa 'suoi+q.�iwi� a�.� o.� aa�;an� .��alqns pup 'anoqq '� uoi.��as ui �.�ao� �as s.}uauaaainbaa '��!I!q!�!la a�� 'anoqp 'g uoi.��as�ui y}ao} .�as sp pauiwaa.�ap uoi��npap a�� o� ��alqns :�a�idsoH aaquaaw q ui aaa� �(�ivaa+oW ao� s�i}aua8 •� 596W-L098 •s�i�auaq sa uiaaaN pai�i�ads pua ao� pai�dda �ou sai�ddns ao sa�inaas �Cuy •p '�Cpoq si� �o +uawa�a ao uo6ao �(ua �o aouop sp �ui��a � �o uosaaa �(q i.ua�+ saainbaa o��n uosaad aa��o ao +uad����aad �(ua o� paaapuaa sa�inaaS 'N . � 'paaoq pup wooa aia�.� ao sasanu �pi�ads '�o+idso� a�� �Cq pa�Co�duaa �ou supi�iu��a� 'suai�is�(�d �o sa�inaas •W !� uoi��as ' � a��i+ay ui paqia�sap sq � '�uauaa6uaaaa sa��naas �puaiuiva ao aab�-��as p uo 's�uai.�bd �Cao.�p�nquaa o� papinoad aao� • � ' uoi��a ' a�i�a �o suoisinoad a�� �+inn a�ubpao��p ui r � . 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� •nno�aq 'Q uoi.}�as ui ao� papinoad s� s�uapuadap paaosuods pub s�uapuadap papn��ui �(�snoinaad aa�{�o a�.� pup ��asaa� ao ��asuai� ao} a6aaano� �anpinipui nnau o+ uoisaanuo� }o .���ia a�� anb� ��a�s 'aapunaaa� �uapuadap b sa papn��ui ua�} �i 'asnods 6uininans aa� ao si� �.�aap }o uospaa �(q aapunaaa� pa�puivaaa� si aa�(o�duaa ua ao� a�aaano� ua�M ' 8 •nno�aq 'Q uoi+aas ui ao� papinoad sa aGaaano� �bnpinipui Mau o+ aapun -aaa�.� papn��ui s�ubd���+apd ��a ao� uoisaanuo� �o ��6ia a�� ana� ��p�s a� '�uaua�o�d -uia }o uoi�r�ssa� }o uosaaa �Cq aapunaaa� pa�auivaaa.} si aa�Co�duaa ua ao� a6aaano� ua�M • y 3J311/�I�d NOIS�3nN0� - III/� 3l�il�b' 59�Y1-0198 il � . .. . . .. . , _ - ' } __ _- . -_ __ -___ - _ .- _ � • ua�d a�� �(q pa�sanb _a.a �C��q�i�i�ads ssa�un aa�(o�du�a a�� }o paainbaa aq ��p�s suaia�� aa�+an� ou pup 'upld a�.� o� a�i+ou aq o� pauaaap aq ��a�s anoqo papinoad so uani6 a�i�oN �SW210� Wldl� '� •uiaaa� papinoad sa�inaas a�� �o �(ua �o�idso� aaquaaua-uou a ui sania�aa �uadi�i.�aad �ua aa�}p a�qissod �t�qbuosaaa Sp UOOS Sp .10 S�I�p ��.Ill�� ui��in� �ua6a paziao�.�na �(�np s�i ao up�d a�� o� a�i+ou ua�.�iann uani6 aq o} asno� ao ani6 � �a�s aa�to�du�a a�l • a�qissod �(�qauosqaa sa aa��paaa�+ uoos sa ua�� pu�a sa�ua+siun�ai� alqplloa+uo�un �(q pa+uanaad ssa�un uoissiwpp �o awi� a�+ �adi�s �aaquaaua si�� �}o �a+idso� aaquaaua �(up �(�i�ou �snw aa�(o�duaa a�l �Wlb'lJ �O 3�IlON � 3 •+�pa;uo� a�� a�b�suiaa �C��n� ��a�s s¢ua6a paziao�+np�(�np s+i �o �(ua ao up�d a�� �(q uaniu�aad ��ns�oa�ua�da��p.�uanbasqns aN.� '��ba�uo� si�� ao� s}uaua�(ad uanivaaad a�� ui apaw aq �I�°faP �I �1N3W31'd1SN1321 '4 • poiaad aaa�(-auo ��ns �o uoi�paidxa a�� aa��a paaapuaa saainaas uoi�azi�p+idso� �o+uno��p uos�i�auaq ao� uaip�� a�uap o� ao a6paano� si� pion o� pasn aq ��a�s a6paano� ao� uoi+a�i�ddo si� ui apaua 's�uauaa�q�ssiw �ua�npnaa� .�da�xa 's�uawa.�a�ssiw ou aa�(o�dwa �(up ao� a6aaano� }o a.�pp ani��a}�a a�{� uaoa� aaa�( auo aa�}y �S3SN3�34 Nlb'1213� NO llWl� 3W11 '� •swniwaad }o �uaw�(ad-uou ao� �da�xa anssi �o a�ap woa� saoa�( onn+ aa��a a�qp.�sa.�uo�ui aq ��a�s ��aa�uo� si�l :Jljlll9`d1S31NO�Nl �8 • anoqa pai�i�ads up�� aa�+o �ua6b �ub o� ao �tq apaua aa.}�aaaa� ao aao�o+aaa� uoi�b�uasaadaa ao asivaoad �(up �(q punoq aq �ou ��a�s up�d a�{1 •a�i��� awoH a�� �aauop �ui+ian� ui �t�uo ua�.} pub'��aa�uo�si�+ �osuoisinoad a�� anipn� ao '�(�ipow 'a6ua�� o� aannod a�� sb� ub�d a�+ �o �ap�aa�aS �ua�sissy up ao �(aa�aa�as a�� 'ao+�aai4 ani�n�ax3 at�� '�uapisaad-a�i^ a'�uapisaad a�+ �(�u� •up�d a�� pup aa�Co�dua3 a�� uaa�n�aq �uau�aaa6p ua��iann �(q 'saiapi�i�auaq aia�� �o ao aapunaaa� paaano�saa�Co�duaaa�.� �o �uasuo� a�� .�no��inn'paaani�ap si +i ��i�nn ui uoi��ipsianl a�+ �o s�na� a�� o.� ��alqns 'auai.� �(ua �a pa6up�� ao papuauaq aq �Caw ��t�.1�U0� Sll�l • Z •�(aai�i�auaq si� o� ao uosaad ��ns o� pa�sivan�} uaaq sa� ao si �uawa{a�s a�� 6uiuia�uo� �uauana.�sui a�� �o �(do� a ssa�un aapunaaa� uaia�� o}o asua�ap ui ao {sa�uo� �(uq ui pasn aq ��a�s paaano� aa�(o�dwa�(up�(q apaua �uauaa�a+sou puo'sai+uaaapnn�ou puasuoi�a�uasaadaa pauaaap aq � � a�s paaano� saa�(o�dwa a�� �(q ao aa�to�dua3 at�� �(q apaua s�uauaa�a�s I I b' '��"a� -uo�aai�ua a�.� a�n+i+suo� ��q�s saa�o�duaa �osuoi�p�i�ddaa�+ pup'o+aaa� pa��a.�.�a si ��i��n �o �Cdo� p'�oaaa�+ aa�(o�dua3 a�� �o uoi+a���ddp a�+ pup .��aa�uo� si�l �S1N3WaN3W'd �l�`d�1N0� ' `d SNOISI/�O�d lb�3N3J - XI 3��Il�b' G. PROOFS OF LOSS: Any obligation for non-member hospital services must be reported to the Home Office of the Plan at Dallas, Texas, by the employee within ninety days after discharge. 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, and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required. H . 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. 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 of rendition of the ser- vices for which claim is made. J . INDIVIDUAL CERTIFICATE: The Plan will issue to the Employer for each covered em- ployee 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." The Plan will furnish a current list of mem- ber hospitals to any employee covered hereunder at any time, upon request, without charge. dlis K . 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. L. COVERAGE DATA; INADVERTENT ERROR: The Employer shall furnish the Plan an application for coverage executed by each employee to be covered hereunder, and all information needed to effect termination and changes in such coverage. Failure or omission on the part of the Employer to furnish the Plan such information shall not de- prive an employee of coverage, but an equitable premium adjustment shall be made _ upon discovery of the error. M. DISCLAIMER: The Plan shall not be liable for any act or omission by any hospital, physician, their agents or employees, in caring for a participant receiving services under this contract, and no responsibility attaches hereunder for inability of any hos- pital to furnish accommodations or services. Benefits are subject to the rules and regu- _ lotions of the hospital selected by the participant, and are available only for illness or injury acceptable to such hospital . N . DISCLOSURE AUTHORIZATION: In consideration of the Plan's having waived phy- sical examination in connection with the application herefor, the employee, on be- half of himself and his covered dependents and sponsored dependents, shall be deemed to have authorized any attending physician, nurse, or hospital to furnish the Plan all information and records or copies of records relating to the diagnosis, treatment, or care of any participant included under this coverage; and such participants shall, by asserting claim for benefits hereunder, be deemed to have waived all provisions of law forbidding the disclosure of such information and records. i_.'__ _. 59BW-{19B m �q/�('_� g�'!'�l'.� .�a •saadad a�aiadoadda ��a �o uoi;n�axa 6uipn�� -ui '�(aano�aa a�� aan�as o� �(aassa�au aq �(aua aana.}o�nn op o+ paaa6p anp� o� pua ua�d a�� o� �(aano�aa �o s��6ia ��ns pau6issp anp� o� pauaaap aq ��a�s 'asp� ��ns ui aapun -aaa� s�i�auaq �uinia�aa �(q '+uad����aad �(uy •papinoad os s�i�auaq a�� �}o �ua�xa a�} o.� �t�uo �nq 'aapunaaat� papinoad aap s�i�auaq ��i�nn ao� �Canlui ao ssaur�i ui 6ui��nsaa +�a �n���i�n �(ua ao a�ua6i�6au ao� uoi+aziva6ao ao uosaad �Cua �suio6a aainb�p �Caua �undi�i� -aad �(ua ��it�n� �(aano�aa �o s��6ia ��ao� pa+a6oaqnsaq �Ipt�s u°Id a�ll �NOIl'd`J0218f1S _ .. :. .- - 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Hospital charges for room and board (including special diets and general nursing — services), except that the amount of such charges over and above the amount stip- ulated in item 15 of the schedule per day shall not be considered hereunder for any purpose. 4. Use of operating, treatment, and recovery rooms. 5. Care in an intensive care unit of a hospital . 6. Anesthetics and administration thereof. 7. X-ray and diagnostic laboratory procedures. 8. Radiation therapy. 9. Oxygen and its administration. 10. Blood transfusions, including cost of blood, blood plasma and blood plasma ex- panders. 11 . Drugs, medicines and dressings used in a hospital . _ 12. Out-of-hospital drugs, but only if "applied for" is marked in item 13 of the sche- dule. 13. Services of a qualified professional physical therapist. 14. 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 hospital only, in the case of Licensed Vocational Nurses. 15. Rental of iron lung or other durable equipment required for temporary therapeutic use. 16. Professional ambulance service used locally to or from the hospital except in con- nection with out-patient care of non-accidental illness. 17. Prosthetic appliances necessary for the alleviation of or correction of conditions arising out of accidental injury occurring or illness commencing after the partici- pant's effective date of coverage hereunder. J. 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Blood transfusions, including cost of blood, blood plasma and blood plasma ex- panders. 10. Drugs, medicines and dressings used in a hospital and those purchased for use out- side a hospital , which require a written prescription for purchase. 11 . 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 hospital only, in the case of Licensed Vocational Nurses. 13. Rental of iron lung or other durable equipment required for temporary therapeutic OM use. 14. Professional ambulance service used locally to or from the hospital . MI 15. Prosthetic appliances necessary for the alleviation of or correction of conditions arising out of accidental injury occurring after the participant's effective date of coverage hereunder. G. CARE means the furnishing of an item of service or supply listed in Section F of this Article I . H . SUPPLIER means a hospital , physician, or other person, firm or institution furnishing OM to a participant an item of service or supply listed in Section F of this Article I . 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PREMIUMS:The Applicant will contribute the portion of premiums indicated below, provide payroll deduction facilities for the employees' portions, and make consolidated group premium remittances. The following shall be the Initial Monthly Premium Rates Hospitalization Supplemental Coverage Total Paid by Paid by Classification Coverage AIS MMS CIS Rate Employee Employer Employee Only $ 5.35 +$ .17 +$ 1.69 +$ XXX = $ 7.21 $2.88 $ 4.33 - Employee & Spouse $ 13.36 +$ .47 +$ 4.65 +$ XXX = $ 18.48 $7.39 $ 11.09 Employee & depend- ent child $ 10.99 +$ .47 +$ 4.65 +$ XXX = $ 16.11 $6.44 $ 9.67 Employee &depend- ent children $10.99 +$ .47 +$ 4.65 +$ XXX = $ 16.11 $6.44 $ 9.67 - Employee, spouse & dependent child or children $14.57 +$ .47 +$ 4.65 +$ XXX = $ 19.69 $7.88 $ 11.81 Each Sponsored Dependent $XXX +$ XXX +$ XXX +$ XXX = $ XXX $XXX $ XXX SPECIAL PROVISIONS: The following stipulations shall be considered a part of this application: SEE ATTACHED SHEET (STIPULATIONS REGARDING CONTINUITY OF COVERAGE) - COVERAGE OF DEPENDENT CHILDREN MAY BE CONTINUED TO AGE 25. SPONSORED DEPENDENTS ARE NOT ELIGIBLE. This application is executed in duplicate, one counterpart being delivered to Group Hospital Service, Inc., and the other to be attached to and become a part of the contract, if issued. CITY OF FORT WORTH F II or corp rate name of Ap licant 06: e, b � - Signature and title Signed at Fort Worth, Texas Witness: - On June 22, 1970 , iT1T/ o Representative of the Plan 0 . - - �- ._ _. _ � __. � - � ,. - _- - ---. ._ ��� - _ -v ,_ . _ ..-_ .._ - J, ,.���'� �-�: uo ��.e� ��dd� o� iunpuapp� s� �.a�us s �u�. �'�. ��u�p � o�. �� �� �uI ° pan ��M aq � ��n� ���.��.uo� rnau ay�. aapun paaano� Gu ituo�aq S�UpCI L� L�.JI�CI o�. uo ��.�u iu:.�a�. s�. � aa�.�e paaapua,� sa� �naas ao� ��e.�� uo� 6u ��.s �xa ay�. aapun s� ��auaq o� �uatua ��. l�.ua < <e �,�o�. pa � �ddp �.��,��uo� ai��. �.o a�u�nss � uodn � ��u� saaaG� .�a�'o �diu� aul •��ea�uo� Mau s�u� �.o wnu��xpiu a�u��a�.�� ���lpaui ,�oCeui au� uio,�� pa��npap aq � < <n� �.��,��uo� .�o �ad � ai{�. ,�apun p lpd s�. ��.auaq < <e ` a6eaano� �p� �paui .�o C�ui L SLM a6�,�ano� �o �.�d a�{�. �.I • po �aad apa�'-an ��. ��u� Gu ian� p��d a.��M s� ��a�a�q U� ��Rrn ao� as�as �p � ao� a�q� � i�n� ac� aana <<<M s� ��au�q ��� ��a�u ,�oCe�u ou `a6�aanoa ssau � ��� �Udoa�.se�.�� � s�r.� aG�.�ano� ao�,�d a���. �I • po�aad �. �,}auaq ��U�. �.o .�apu � nuia� aU�. ao�. ��� �Ma,�aU�. a�uep,�o��� u� s� ��.auaq an �a�aa o�. anu ��uo� ��p�{s `a�.ep uans uo �.�a�.�.a u� po�.�ad �i�.auaq p u�ns anpU w���� ,�adoad uodn p�no� ,�o `�.�a��a u � po laad �. �,�auaq pa�s � �q��.sa u� s�y uaU�. ourn � �.ua�ua �ddns �p� �paui .�oCe�u Mau a���. aapun a�.�p an��.�a�}�.a a6�aano� s�� o�. �o�,�d �C�a�.��p��utu� a6�,�ano� ssau � �� � Ll�CIOa�SL��L� �to �e� �paui aoCeui sso.�� an �s 6u ip �ou �upd �� ��..�pd �{�ns �'u� `a6�,�anoa .�o iad a��. �o s� s�c� aU�. uo aq << �rn a6e,�ano� Mau aU�. �.o a��p an ���a�.�.a �u�. aao�.aq 6u ��uau�woa suo �ss «upp �e� �dsoi� � �� ,�o�. s�. ��.a�iaq ` �'�u�u6aad au� �.o uo ��.da�u � au�. �.e �.�a�}�.a u� aF�e.�ano� �.o s �s�q a���. uo aq �� iM aae� �'�. �u,�a�.��u ao�. s� ��.auaq `�.ua«i -au ��.uo� ��:} �dsoi{ �}o po �aad �.o uo ��. �u �,}ap au� aapun pa6.�p��� aq << irn pasn s�'er ` spo �aad 6u ��. ��M �.su �e6� paua�a a�u��. ,ao,} par�o L lp a9 L L �M ��paa� suo �s �noad �e t�ads asa�{�. �.o �1dea6e.�Ld �.s.� ��. au�. u� paq �.��sap S�.ULCI L� L�.aLCI .�ai{�.o �'u� .�o� •a6e,�ano� ao�.�d o�. anp pa�npa,� aq �ou ���us s�unu�txpu� �L�Lp�IU aoC�ui a��. `a��,�ano� ,�o �ad au� �o s� s�q a�{�. uo aq <<<r�ti af e.aano� rnau au�. �.o a��p an i� �a��a ay�. a,�o�aq 6u ��uau�uioa suo � ss iwpe �e�. ldso�� ��� .�o� s�. ��.auac� ` pan �onu L�'�ueu6aatl au�. �.o uo ���u �u�.�a� o� ao �.�d sa��u �uiaa� ��e.��.uo� Mau au�. aapun a6�aano� aa�� �6no�{� uan� s�. ��.auaq �'�. �uaa�.��u o� � ua ��ed ��� �a�.a�.sqo au�. �.o �.�� i,� a�{�. 6u �pn ��u � `�C�u�ufa.�d ��ns o�. a �q�� � �dd� aq o� anu i�.uoa � �e��s a6�a�no� ao �.�d ai��. aapun a,��� �'�. �uaa���u ,�o�. �'�. <<<c� �6 ��a ao� suo � s lno.�d ai��. �.eu�. �.da�xa : a6�aano� N�au au�. ;}o s � s�q au�. uo aq <<<in �.�e.��uo� Mau a���. �.o a�.�p an ��.�a�.}a au�. uo Gu �aq u��'�upu�aad �Cue .�o� �'� �u,�a�e�u ,�o�. s� ��auaq ` spo �aad Gu ��. ��rn �.SU LLBL pauapa aua�a. ao�. 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The coverage factors in the new Schedule of Specifications will apply to all services rendered to each participant under r this contract on and after the effective date stipulated above; except that: (a) Benefits for maternitycare will be under P p the terms of the Blue Cross contract or membership agreement as in effect at the inception of the pregnancy; and (b) Benefits during all hospital admissions commencing before the effective date stipulated above will be under the terms of the coverage as in effect at the commencement of the hospital admission. 2. Any period of hospital confinement having commenced but not ended before the effective date stipulated above shall be continued after such effective date, and the days of hospital care used during such period of hospital confinement 1I+ before such effective date shall be subtracted from the "available number of days" of this new Schedule of Specifications for the remainder of the period of hospital confinement involved. 3. Any participant holding Blue Cross major medical or catastrophic illness coverage immediately prior to his coverage effective date under this new Schedule of Specifications, who then has a benefit period in effect thereunder, shall continue to receive benefits in accordance therewith for the remainder of that benefit period, and Major Medical Benefits of this Schedule of Specifications will not be available for a disease for which benefits were paid during such benefit period until the end of such benefit period. If the prior coverage was a major medical coverage, all benefits paid under the prior coverage will be deducted from the major medical lifetime maximum of this Schedule of Specifications. — Proposed Monthly Premium Rates Hospitalization Supplemental Coverage Total Paid by Paid by li ' Classification Coverage AIS MMS CIS Rate Employee Employer .. Employee Only $ 7,35 +$ ,25 +$ 4.30 +$ XXX = $ 12.40 $ 3.10 $9.30 Employee&Spouse $19.6 +$ 69 +$ 11.86 +$ XXX = $ 32.15 $22.85 $ 9.30 Employee & Depen- dent child $1 +$ +$ +$ _ $ S 6.1t .69 1!„86 XXX 26.67 $19.37 9.30 Employee & Depen- dent children $16.12 +$ .69 +$ 11.86 +$ XXX — $ 28.67 $19.37 $ 9.30 Employee,spouse& dependent child or children $21.37 +$ .69 +$ 11.86 +$ XXX = $ 33.92 $24.62 s 9.30 i Each Sponsored Dependent $XXX +$ XXX +$ XXX +$ XXX = $ XXX $(XX $XXX It is understood and agreed that the proposed monthly premium rates are subject to acceptance by Group Hospital Service, Incorporated, at its Home Office in Dallas, Texas. This application is executed in duplicate, one counterpart being delivered to Group Hospital Service, Incorporated and the other to be attached to the Contract. Signed at Fort Worth, Texas CITY— OF FORT WORTH r Full or Corporate Name of Applicant 4.-P?ArAcil'Aei R on / -�.q D3 by_ r,LP :.____ / 1.,, e R r 'r 7 ll Witness: Signature and Title !_ `���� LJ OCT ,„ 22 1973 40J 4 / PR;,SIDENT Representative of the Plan 1593-M1167 GROUP HOSPITAL SERVICE,INC. ri ran,'P r'rF.e trr,-str/r4V.S!!^JM'CECC. 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HOSPITAL ADMISSION means the period between the time of a participant's entry into a hospital as a bed-patient and the time of discontinuance of hospital care or discharge by the physician, whichever first occurs. The day of entry, but not the day of dis- charge or departure, shal I be considered in determining the length of a hospital admission. I . PERIOD OF HOSPITAL CONFINEMENT means the combination of any number of hos- pital admissions of a participant, excluding admissions for maternity care, until there is an interval of at least ninety (90) days between any two consecutive admissions. J. BENEFITS means payment by the Insurer to apply on the charges of a physician for services covered herein. K. INSURANCE YEAR means each succeeding twelve-month period, beginning on the effective date of coverage hereunder for the employee concerned, whether the care invoking benefits is rendered to the employee or to a dependent or sponsored depen- dent under his coverage. L. INSURANCE MONTH means each succeeding monthly period, beginning on the policy MID AMENDED- date. Sae Art. X M. POLICY ANNIVERSARY means the month, day and year specified in the application MID Sec.L. and the corresponding date in each year thereafter for as long as the policy is in force. N . SCHEDULE means the Schedule of Specifications appearing in the Employer's applica- _ tion herefor, or the latest of any revised schedules submitted by the Employer and ac- cepted by the Insurer to replace one previously effective. O. PRE-EXISTING CONDITION means any abnormal physical or mental condition, whether active or inactive, existing before the patient became a participant hereunder, in- cluding all deformities, ailments or prior injuries which may thereafter become aggra- vated by subsequent injury or disease. 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The patient is classified as employee or primary icnsured under the other cov- erage and as dependent under this policy, or as dependent of a male person under the other coverage and dependent of a female person under this policy; or, if those conditions do not exist, b. The effective date of this patient's participation under the other coverage is earlier than the effective date of his coverage hereunder. 2. Determination of benefits under this Section F shall be made in relation to the services furnished bya physician in each "case," consisting of any item of profes- sional service specified in Article V, or the combination of all such items of ser- vice rendered on any one day. 3. When this Section F is applicable, the medical-surgical benefitsof the other cov- erage shall be deducted, item by item, from the charges of all items of medical- surgical service for which any benefit is provided under Article V hereof, or other coverage, and the Insurer will pay the remainder of the charges for such items; provided, however, that in no event shall the provisions of this Section be con- strued to increase the amount of total benefits which would be payable in any case hereunder in the absence of other coverage. 4. When benefits are provided by other coverage for more than one item of service in an 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. 5. The Insurer assumes no obligation to discover the existence of other coverage or the benefits payable under it if discovered, but only to give effect to the provi- sions of this Section F in accordance with information furnished it by an authori- tative source. It shall, however, be entitled to obtain and/or to release such in- formation as reasonably necessary to give effect to these provisions, without the consent of or notice to any person; and any person claiming benefits hereunder shall , as a condition precedent to his right of recovery, furnish to the Insurer full information concerning the existence of other coverage and the benefits thereof. 6. The Insurer shall be entitled at any time to recover benefits paid in excess of its obligation as determined under the provisions of this Section F, irrespective of to whom such benefits were paid, from an issuer or provider of the other coverage, ` or any person or firm to or for whom such payment was made, or from any combi- nation of such sources. 7. When benefits have been paid under other coverage the Insurer shall have the right, in its discretion, to payover to the issuer or provider of such other coverage any portion of the benefits available under this policy which the Insurer may deter- mine to be due in order to give effect to the intent of this Section F and corre- sponding non-duplication provisions in such other coverage. The amount so paid shall be deemed to be benefits provided under this policy, and to the extent there- of, the Insurer shall be fully discharged from liability hereunder. ose OLSW-9Z6C 00'08l 00'09 00'S£L 00'S� 00'SZl 00'S� 00'05L 00'OZZ 00'S� 00'S� 00'06 00'OLL oo'o<< 00'OLL 00' OL L 00'OEL 00'09Z 00'SlE 00' 06Z 00' S6 L 00'OE� 00'08L $ $ $ a�up�nol Ib' uanuaixqw O � uoi��npaa uado uoi��npaa paso�� 'aau� uoi��npaa uado uoi��npaa paso�� '�noq13 uoi.��npaa uado uoi+�npaa paso�� 'a��uy uoi.�a�o�sia 6a� aannol diH }o uoi�p�n�i.�apsi4 aa6ui� ao j pupH aai�u3 .�oo� uaaoaao� way 'uoi�o�nduay uopuaj ao �uio� 'auo8 �paa�a�iq �paa.�b�iun '�auin6ui 'oivaaH �p�o�-qns �p�o� '�Cwo��aa.}sp� uo���asa� uo�o� �(wo��a�s�C�a �o�� �Cwo.}�apuaddy �ivaa�dqns ao �i.}ouapa�dpipqns 'ssa�sqy uawopqy 9t�� L ���L Z6ZL O6Zl LS£L 55£L L9Ll 8�LL 9ELl ZO 8 L ZZLL Z8L� 80LL SOL� 8�9� (E9� SLIE �LLE 8L1� SLS� 19Z� SLSE apo� aanpa�oad •aaansu� a�� �(q pauivaaa� -ap sb 'sisaq a�auoi}aodoad p uo apaw aq ��inn pa}si� �ou saanpa�oad �p�i6ans ao� .}uaw�tbd • pawao�aad saanpa�oad ani�naado aa��o IIp -�O} �J21�1�2CIS S2�UpM011p a�� }o �It�l�-2U0 Sf1IC� a�UpM011p �sa�aaa6 21�+ Spl� l��II�M aanp -a�oad ao uoi�aaado �b�� ao� a�uon�o��a a�� o+ pa�iwi� aq'pai�i�ads asi�naa�¢o ssa�un '��inn a�qa�(ad �unowp �a�o� a�� 'sa��noadda �b�i6ans �uaaa}}!p �q ao s6uivado �o�i�ans �uaaa� -�ip �6noa�� awi� awas a�� +o pauaao�aad aaa saanpa�oad ao suoi�aaado aaoua ao onn� ua�M •piod aq ��i�n a�uanno��p �sa�6i� a�� 6uipubuauao� aanpa�oad a�{; 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XI 31�11�`d 1 G. PROOFS OF LOSS: Written proof of loss must be furnished to the Home Office of the Insurer at Dallas, Texas, by the employee within ninety days after any partici- pant under his coverage receives services for which benefits are provided herein. 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, and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required. H. TIME OF PAYMENT OF CLAIMS: Benefits payable under this policy for any loss will be paid immediately upon receipt of due written proof of such loss. I . LEGAL ACTIONS: No action at law or in equity shall be brought to recover under this policy unless brought within three years after the date of rendition of the services for which claim is made. J. INDIVIDUAL CERTIFICATE: The Insurer will issue to the Employer for each covered employee an individual certificate setting forth a statement as to the insurance pro- tection to which he is entitled, to whom the benefits are payable, and the provisions of the Article of this policy entitled "Conversion Privilege." K. 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. L. COVERAGE DATA; INADVERTENT ERROR: The Employer shall furnish the Insurer an application for coverage executed by each employee to be covered hereunder, and al I information needed to effect termination and changes in such coverage. Fail- ure or omission on the part of the Employer to furnish the Insurer such information shall not deprive an employee of coverage, but an equitable premium adjustment shall be made upon discovery of the error. M. DISCLAIMER: The Insurer shall not be liable for any act or omission by any hospital, physician, their agents or employees, in caring for a participant receiving services under this policy, and no responsibility attaches hereunder for inability of any hos- pital to furnish accommodations or services. N. DISCLOSURE AUTHORIZATION: In consideration of the Insurer's having waived physical examination in connection with the application herefor, the employee, on behalf of himself and his covered dependents and sponsored dependents, shall be deemed to have authorized any attending physician, nurse, or hospital to furnish the 111111 Insurer all information and records or copies of records relating to the diagnosis, treatment, or care of any participant included under this coverage; and such parti- cipants shall, by asserting claim for benefits hereunder, be deemed to have waived all provisions of law forbidding the disclosure of such information and records. 598W-OZ6L •saadqd a.�piadoaddq ��a �o uoi�n�axa 6uipn��ui '�taano� -aa a�.� aan�as o.� �(aassa�au aq �Caua aana+a��n op o.� paaa6q anq� o� pup aaansu � a�.� o.� �Caano�aa �o s.���ia ��ns pau6issp ana� o.� pauaaap aq ��a�s 'asp� ��ns ui aapunaaa� s.�i� -auaq 6uinia�aa �(q '�uadi�i�aod �Cuy •papinoad os s.�i�auaq a�.� �o �ua.�xa a�.� o� �C�uo .�nq 'aapunaaa� papinoad aaq s.�i�auaq N�i��n ao� �(anlui ao ssau��i ui 6ui}�nsaa .��q �n� -�IIM /CUt� aoa�ua6i��auao� uoi.�qziuq6aoao uosaad �tuq�suiq6aaainb�a �Caw �uad����aod �(uq ��i�M �aano�aa �o s.}t�6ia � �a o� pa.�a6oaqns aq � �q�s aaansu I a�ll �NOIl`dJ0219f1S ' d •aaansu� a�+o� }uaua�tqd ��nspun�aa'puawapuodn'��q�s�Cqaaa�.�6ui.�i�auaq +undi�i�aad aa�.�o ao aa�(o�dwa a�� 'pa��i�ua �C��p6a� .�ou sann �uai�pd aN.} ��i�nn o� aapunaaa� piqd uaaq anq� s.�i�auaq �q�.� pauiwaa�ap aq ��p�{s �i ua�nn pua �I �S11�3N39 �O aN(1�321 'O 0 � ��v •nno�aq 'Q uoi��as ui ao� papinoad sa a6aaano� �anpinipui nnau o.� uoisaanuo� �o ��6ia a�� ana� ��a�s a� '��/� a��i.}ay �o Q uoi.��as ao � uoi.��as ui papinoad suosbaa a�.� �o �Cup ao� aapunaaa� pa.�ouivaaa; 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MINIMUM ENROLLMENT REQUIREMENTS: The Applicant certifies that 4328 employees are eligible to make application for coverage at the date of this group application, and agrees that at least 75% of that num- ril ber (10 minimum) must make application for coverage before the policy date; otherwise this application shall be deemed to have been withdrawn. PREMIUMS: The Applicant will contribute the portion of premiums indicated below, provide payroll deduction facilities 7 for the employees' portions, and make consolidated group premium remittances. The following shall be the Initial Monthly Premium Rates Paid by Paid by Classification Rate Employee Employer 11111. Employee Only $ LS $ .46 $ .69 Employee & spouse $ 2.66 $1.06 $1.60 Employee & dependent child $ 2.27 $ .91 $ 1.36 .. Employee&dependent children $ 2.27 $ .91 $1.36 Employee, spouse & dependent child or children $ 3.39 $ 1.36 $2.03 Each Sponsored Dependent $ XXX $ XXX $XXX m. SPECIAL PROVISIONS: The following stipulations shall be considered a part of this application: SEE ATTACHED SHEET (STIPULATIONS REGARDING CONTINUITY OF CJVERAGr ) COVERAGE OF DEPENDENT CHILDREN MAY BE CONTINUED TO AGE 25. SPONSORED DEPENDENTS ARE NOT ELIGIBLE. This application is executed in duplicate, one counterpart being delivered to Group Life & Health Insurance Company and the other to be attached to and become a part of the policy, if issued. oft CITY OF FORT WORTH /I ull or corporate name of Applicant s / `� ' 2 I�%/I� �'' - !►"tom, .... by � L !' Signature and title Signed at Fort Worth, Texas Witness: On June 22 , 1970 �j i Representative of the Insurer �� � :uoi.}a�i�dda o� uanpuappq sb .�aaNs siN� �t�.i.�uapi o.� �ai.�iu� �� � • paniaM aq � � inn �(�i �od nnau a�� .�apun paaano� 6uivao�aq s�updi�i.�.�pd o.} uoi.�puiva.�a.� s�i .�a.��.a pa.�apua.� sa�in.�as .�o� �(�i�od 6ui.}sixa a�� .�apun s.�i�auaq o� �uau�a�.�i�ua ��a '.�o� pai�dda �(�i�od a�.� �o a�upnssi uodn '.�q�� saaa6p aa�(o�du�3 a�l • a6a.�ano� .�oi.�d a�.� �o sisaq aN.} uo aq � � inn a6paano� Mau a�.� �o a�ap ani.��a��a a�� aao�.aq �ui�uau�u�o� suoissivapa �p�idsoN ��p ao� s�i�auaq (p) '�t�upu�a.�d a�.� �o uoi�da�ui a�.} .}a .}�a��a ui a�p.�ano� �o sispq a�{� uo aq � � �nn a.�b� �(.��u.�a.}aua .�o� s�i�.auaq (�) '�uau�au��uo� �a�}idso� �o po�.�ad �o uoi.��ui�ap a�.� aapun pa�.�aN� aq ��in� pasn s�(ap (q) 'spoi.�ad 6ui�iann �suia6a pau.�aa auai.� ao� pannollp a9 II!N` �!pa.�� (a) :suo�sino.�d �bi�ads asa�� �o �db.�6b.�pd .�s.�i� a�� ui paqia�sap s.}uadi�i.�.�ad .�a��o �(ub .�o� • a6a.�ano� .�oi.�d a�� �.o sisaq a�.� uo aq � � i�n a�a.�ano� nnau a�.� �o a.�qp ani.��a�.�a a�� a.�o�aq 6ui�uai,ui.uo� suoissiwpp �a.�idso� ��a ao� s���auaq (�) 'pan�onui �(�uau6aad a�� �o uoi.�buiva.ta� o� .�oiad sa.�pu�ua.�a.� �C�i�od nnau a�.} aapun a6q.�ano� .�a� ��no�� uana s.�i�auaq �(.�iu.�a.�aw o.� .�uai�ad �a�ia�a�sqo a�.� �o .���ia a�� �uipn� �ui '�(�uau�aad ��ns o.} a�qp�i�ddp aq o.� anui.�uo� ��p�s a�a.�ano� aoiad a�.� .�apun a.�p� �(.}�uaa.�aw ao�, �(�i�iqi�i�a .�o�. suoisinoad a�.� .}a�� .}da�xa :a6a.�ano� nnau aN.� �o s�sbq a�.� uo aq ��inn �(�i�od nnau a�.� �.o a�ap ani.}�a��a a�.� uo 6uiaq ui �(�uau6a.�d �(ua .�o� aaa� ��iu.�a.�bu� ao� s.�i�auaq (q) 'spoi.�ad 6u�.�iann .�suip�p pauapa awi.} ao�. pa�no��a aq ��iM �ipa.�� (a) :ao� pai�dda �t�i�od a�.} �o a.}ap ani��a��a a�.� o� .�oiad �(�a.�pipauauai aa�(o�dua3 a�� �6noa�� a6a.�ano� 6uip�o� �dba6aapd 6uio6aao� a�.� ui paqi.��sap .�uadi�i.�aad �(up .�o� •suoi.}a�ndi�s �wnno��o� a�.} o.� ��alqns 'a�a.�ano� snonui.}uo� pa.�apisuo� aq ��inn .�uauaaa.�6b di�s -.�aquaaua .�o �(�i�od p�aiNs an18 �ua .�apun a6p.�ano� si� 6ui�p�da.� �(�i�od Mau a�.� aapun �ubdi���aad �Cua �o a�aaano� pua 'a.}ap ani��a��.a s�i o.� aoi.�d �t�a�aipawuai .�a�(o�dw3 a�.� �(q pla� �(�i�od �a�i�ans-�b��paw dno.�� p�ai�s an18 �(ua a�a�daa ��iM 'panssi �i 'ao� pai�ddp �(qa.�a� �(�i�od a�l •a�a.�ano� �o �(�inui�uo� 6uip.�a�a� suoi�p�ndi�s SNOISInO�d lb'1�3dS ,r � �' :� � ;� i � '` ,� , ... � _'. in" i, � �: �r.,j ;, , j �:, i` . � J • ---- - -- - -- - --- - - - - -�- ----- - --- - --- -- ----- -- - wnwixoW 'Sl $ � �11�3N39 al'd 1S2i1� J.�N3J�3W3 , •�•� --------- ----- -----------------------------suoi�ipuo� 6ui�sixa-aad �o a�o� ao� '1�l ; ; '�•�J ----------------•-------------------------------------------- -------------------------------------aaa� �o�i��a}sqo ao� Et �Sa01�3d JNlllb'M saiaas �a��j ---------------------- ---------------------------------------------------------------------------- sa�upnnollb' �i�aua9 �Z� �Jldb213H1 N011b'I4�/?l •9•� �--------------------•------------------------------------------�-------------------------------- wnwixaw �(ao�oaoqal 'l l ���%�i �--------------------------•-----•------------------------------•--------------------------------------- uanwixaW l�p�-X �Ol saiaas '�'j� --------�---••------------------------------------------------------------------------------------- sa�uo�nollt/ �i�aua8 •6 �J��Olb'�08b'l aNd l�`d21-X �IlSON�b'Ia s�(ap '�`�J �o iunwixpw a o� d� •g 'a'N � �(pp �uanbasqns y�aa pub y�ano� •� '�'N� �(op p��yl �q "�`� � �(op puo�as •s '��N� �(ap �sai� •� � �uaa�n�uo� �] ani�puaa�lf/ `S11�3N38 lb'�1a3W lb'lIdSOH-NI o�o '�'i� -----------------a�uo�no��a �o�ia}a}sqo ao �p�i6ans a�qa�i�ddp }o a�a�ua�aad — J!}aua8 •E �b'IS3H1S3Nb' saiaas���PJ -------------------------------------- -------------------- ----�----------------------------------- sa�uaMollb' �!}auae �Z �S�I?J131S90 saiaas � � �N --------------------------------------------------- ------------------------------------ sa�up�nollf/ �i�aua8 • � �,��3��ns ,•�o� pai�ddp �ou �o a�qa�i�ddoui ao}�o� a6a�ano�„ subaw a�ods �(uo ui XXX :S�upl9 Ilp a�a�dwo� „•a�npay�s snoinaad uo u�noys so aiuos 'a6uoy� oN„ suaaw a�ods �(ua ui '�•N �SNOIl`d�1�1�3dS �O 31f143H�S ���� -'ON J��IIOd 3�Nd21f1SNl Id�IJ21f1S-lt/�143W 431�/21 3�N31�3dX3 319b'll3�Nb'�-NON uo }�a}�a ui �(�snoinaad auo ay� ao} suoi�a�i}i�ads }o a�npay�s 6uinno��o} ay} }o' ani��a}�a 'uoi�n�i�sqns ao} soxal �StJIIqQ � - c%7LY�`1{l'}'�/U� � � i � � a � a z d�o�.z �I T I� � . �I � o� apbW �(qaaaH s� uoi}a�i�ddy pm Proposed Monthly Premium Rates Paid by Paid by Classification Rate Employee Employer Employee Only $ 1.86 $ .46 $ 1 .40 Employee & spouse $ 4.33 $ 2.93 $ 1 .40 Employee &dependent child $ 3.70 $ 2.30 $ 1.40 Employee&dependent children $ 3.70 $ 2.30 $ Employee, spouse & dependent child or children $ 5.52 $ $ 1.40 2 1 O Each Sponsored Dependent $ XXX $ XXX $ XXX �• It is understood and agreed that the proposed monthly premium rates are subject to acceptance by Group Life & Health Insurance Company at its Home Office in Dallas, Texas. pm It is further understood and agreed that if this application is accepted, the Policy shall be deemed to be amended in all respects necessary to give effect to the following, but not otherwise: on 1. The coverage factors in the new Schedule of Specifications will apply to all services rendered to each participant under this policy on and after the effective date stipulated above; except that: (a) Benefits for maternity care will be under the terms of the Blue Shield policyor membershipagreement as in effect at the inception of pregnancy; and (b) Benefits aft during all hospital admissions commencing before the effective date stipulated above will be under the terms of the coverage as in effect at the commencement of the hospital admission. 2. Except as provided in Paragraph 1, above, any period of hospital confinement or insurance year having commenced am but not ended before the effective date stipulated above shall be continued thereafter, subject to the benefit maximums of this new Schedule of Specifications. on Application is also made to amend the Policy, effective on the same date, as follows: By changing the policy anniversary date to October 1 . Sponsored Dependents are not eligible. Coverage of Dependent Children may be continued to age 25, except that coverage of disabled children may be continued to any age. This application is executed in duplicate, one counterpart being delivered to Group Life & Health Insurance Company and the other to be attached to the Policy. A Signed at_ort Worth, Texas CITY OF FORT WORTH Full or Corporate Name of Applicant 1114 on_ 2 q , 19 17 3 by / _/Ld ' i ''e -Y w +' r Signature and Title LSU U lC D Witness: Lnl i L5 r� OCT 22 1973 *ever', C PRESIDENT Representative of the Plan GROUP HOSPITAL SERVICE,INC. 7405-M370 GROUP LIFE&HEALTH INSURANCE CO. °{��n�r���ao ��a�J�� �iui,�unao�� ac�¢ �uwa��,� E'!a� sr.c.al��� �(.��u.�a�.pw �o '%�� �� ��c�t�a �a.►as�a ,(�q�eaa.g�;.u'c���w�3.� c� (c�) sr���i ��3�l,i�,� �Li1�Uf10���j' l�9('f5 �C1BJt1� �3�JJt3�U1 aC� IaiPt�g diJ S! s.�:��uac� .���. �(.�6(i�i�'fl ra ��e�nn .a��} �,�n�onui pa�aa� 6urT�a�aa��� ��.} �ca �u�3 e�; k;u;r�n8l�o� s�ta� ���) �.��ea;u ue�'.�;�n �a�n� ao ;taa�ueer��i Gui�uad swt�a�� y��'�H ii;� �o i�.�o.� ��i; i5} 'nf;� 'p�saad t�u�.�u�p��� yaets }a pua at�� 6u�,v�c�fla� sf�� �O�l� e(,�x;s uiy�€ir,� �i���� �a� ��sy,w pup p�ngon�ti �oia�� �iu�.�uno��y aE�� �uiar�;� °sa'�ale,� pua 4s�s�e6.�����n; �:�Bul �r�.�uepa��`� a;ay.� �uipn�� _cae �nq s��aau�a���,��, f�al�'�,hi aolc�4� ���y� �u��n��x�) s�ar�i��o� �y.� �o s�a��smn�.�� .��auaW ��.� a��aun �a:�.unau� ss���al� It�' �� d�'�°� �fl�� ��') sn��� `{�t�%��'�) �uaa .aa� }�ay—auo paa ano� �(c;� sa¢��I�;� �c�� jos pan���ug poi.t�,� ����una��� ay� ao� �rj;�asF�.c� .g;s��a�g ��� �0=.3;.�Ir��a (`) s�`���� `(<'loZ;/�—�) �u�� .ta;�! �`Al�maua ta��a�� �n�.� fc{ (s;udc�a���n� l.�r�iu� �::�.�uapo�;,�,-� .t�de�.� €�us�s�l� -�uo ,�r�cy s.�+�awa'�icl��� ��ai�d'�V acat�t� .�aad3.� �ul�n��x�) s.��aa}ua� a�,� 1c�� �a�n�o�u! x��o�dd �u�g�.�aa����;� �i�� ao� u��iw�a,� .��so<.�� a��. �,��.��n�w {Z) sn��:� '�i'oi1� �c� s.�u�ur���ldnc� Ir��rP�`�V .rolat�y ay� ao� pdn�s�n�;s p�rg.+a� t��a����:��;� a:�� .�o� u��+;�.taa� .gisr���� a�,� e46di,��€��aa (�} :�u;n��esl�o� �y� $o uoi.�auA��oa b sn pnm3�� 6UI,�uflC3��� Ua U6 �9D��un ;aq pa.�anaua st�!;r��� F�ug�caust.�sa �� �o�;aw ��sgnaa ►�uannog��� �y} �u��r��l�sc��s s;�� 's�ua��} s.ag �s.�;nn �auka�,ao���_, �aa "� sac�a.�a�, '(ai5li0lSBl10J� �L?J�tAd�„j itP �8�:#av' °ZLGI °t �1�°9" �ni.p����.e °�u;�u�iza�s �,� °(;. 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PROPOSED PLAN If rendered by a Medical Doctor - 20% of amount paid operating surgeon. 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