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HomeMy WebLinkAboutContract 45447 (2)OFFICIAL RECORD CITY SECRITARY 14 TX DISCLOSURE AG' E€Ei`1'EiIVZR • ReliaStar Life Insurance Company, Minneapolis, V1N A member of the ING family of companies (the "Company") Policy Effective Date 0 4 / 01/2 014 Plan Sponsor Name The City of Ft . Worth INSTRUCTIONS FOR COMPLETION OW v CA_SkL/TRR©T s 7 " i .. 11. ..-T-EIVED MAR 24Tr _ ING f 1' Your future. Made easier.'F-' (C Or r;A`J 4) D�=r V•. ti.� Please provide the information described in the Disclosure Reports Section below and then have an authorized representat*ivw-f an Sports i sign the Disclosure Agreement below. The Company shall use the information provided solely for the purpose of evaluating the risks brit g 9:1@d"or renewed Excess Risk Insurance Policy ("Policy"). Prior to submitting this Disclosure Agreement and Disclosure Reports to the Company, please consult with your current Claim Administrator(s), Utilization Review Firm(s), Case Management, and Pharmacy Benefits Managers) (collectively, "Claim Vendors"), and Plan Sponsor's Broker or other insurance advisor. The Disclosure Reports must be provided to the Company no earlier than 90 calendar days prior to the Policy's Effective Date or renewal date, as applicable. Should the Company require any additional information, it will notify the Plan Sponsor and/or its designated representative in writing no later than 20 calendar days following receipt of the Disclosure Reports. Any firm quote is void unless accepted by the Plan Sponsor in writing within 35 days from the date quoted by the Company. DISCLOSURE REPORTS (Plan Sponsor shall attach the following reports or data (include claimant name, primary ICD-9/ diagnosis) hereinafter referred to as the ("Disclosure Reports") • Any individual with paid claims that has exceeded 50% of the stop Toss deductible during the applicable current policy year (minimum 9 months): • Any individual with denied and/or pended claims that has exceeded $25,000 during the applicable current policy year (minimum of 9 months): • Any individual evaluated and/or listed for an organ, stem cell or bone marrow transplant: o Any individual diagnosed with a condition, during the applicable current policy year, represented by any of the ICD-9 codes contained in the attached list including claim amounts, as well as any individual who is in case management during the applicable current policy year (minimum of 9 months). DISCLOSURE AGREEMENT The Plan Sponsor submits this Disclosure Agreement and the attached Disclosure Reports to the Company to induce the Company to issue an Excess Risk Insurance Policy ("Policy") or to renew an existing Policy. The Plan Sponsor represents to the Company, to the best of its knowledge and belief, and after making a diligent and good faith inquiry, that (i) all information contained in the Disclosure Reports is complete, true and materially correct;(ii) prior to submitting this Disclosure Agreement and Disclosure Reports to the Company, Plan Sponsor reviewed and discussed such Disclosure Reports (together with all pre -certifications, case management notes, claim files, and pharmacy benefit management files and notes) for both the current policy year and each year thereafter during which the Company provided excess insurance coverage to Plan Sponsor, with its Claims Vendors, broker or other insurance advisor; (in) it has reviewed this Disclosure Statement and the attached Disclosure Reports with its Broker or other insurance advisor, and has fully read and understands this Disclosure Agreement; and (iv) as of the date of signing of this Disclosure Agreement there are no known potential catastrophic claims other than those disclosed on the attached Disclosure Reports. The Plan Sponsor understands and agrees that: (i) the Company will rely on this Disclosure Agreement and the attached Disclosure Reports to (i) underwrite this risk, (ii) determine whether or not to issue (or renew) a Policy, and (in) if the Company agrees to issue or renew a Policy, determine the terms, conditions, limitations and rates of or for such Policy. The Plan Sponsor further understands and agrees that (i) if such Disclosure Reports are incomplete or untrue, and such incompleteness or falsity is material to the risk to be insured by the Company, any Policy issued or renewed by the Company may be rescinded, any benefits that might otherwise be payable thereunder may be denied, and/or the premium rates, deductibles, terms, conditions and limitations of the Policy may be revised by the Company; and, (ii) its complete and accurate disclosure of known potential catastrophic claims is a condition precedent to issuance (or renewal) of the Policy. In the event the Disclosure Reports are not timely submitted to, and approved by, the Company within 45 days following the Effective Date or renewal date of the Policy, the Company retains the unconditional right to deny any claim, adjust the rates or its underwriting terms, and/or rescind the Policy at any time, and such right shall not be impaired as a result of the Company's acceptance of premium. Plan Sponsor verifies that to the best of its knowledge and belief, and after making a diligent and good faith inquiry, the Disclosure Reports herein and hereafter provided is (are) accurate and complete. Plan Sponsor Signature By (Its Corporate Officer or Other Authorized Representative) Title ' c k Jv\ `I V A a tko. RL-SL-DISCLOSE-2013 Page 1 of 2 - Incomplete without all pages. A figteJet -AS cm FatitA CEzz fict,t rti Date l i `'I i Order # 164721 12/06/2012 As*. trim Airy No ditP c. R3/45416 ICD=19 CODES FOR DISCLOSURE NOTIFICATION Please list all Plan Participants who have been diagnosed with Benefit Period: Neoplasms 140-239 Neoplasms Endocrine, Nutritional, Metabolic, Immunity 277.0 Cystic Fibrosis Diseases of the Blood and Blood -Forming Organs 284.9 Aplastic Anemia NOS 286-286.9 Coagulation Defects and/or Hemophilia Diseases of the Nervous System and Sense Organs 344.0-344.09 Quadriplegia and Quadriparesis 344.1 Paraplegia 348.0-348.9 Encephalopathy Diseases of the Circulatory System 410-410.9 411-411.89 414-414.05 415-415.19 416-416.9 417.1 421-421.9 424-424.9 425-425.9 427-427.9 428-428.9 430, 431 434.9 436 440-441.9 Acute Vyocardial Infarction Acute and Subacute Ischemic Heart Disease Coronary Atherosclerosis (ASHD) Acute Pulmonary Heart Disease Chronic Pulmonary Heart Disease Aneurysm of Pulmonary Artery Acute and Subacute Endocarditis Valve Disorders Cardiomyopathy Cardiac Dysrhythmias Heart Failure Subarachnoid / Intracerebral Hemorrhage Occlusion of Cerebral Arteries Acute Cerebrovascular Accident (CVA) Atherosclerosis / Aortic Aneurysm Diseases of the Respiratory System 480-486 490-496 515 518-518.89 or treated for any of the Codes listed under the following categories during the current Diseases of the Genitourinary System Pneumonia Chronic Obstructive Pulmonary Disease (CORD), etc. Postinflammatory Pulmonary Fibrosis Pulmonary Collapse and/or Respiratory Failure Diseases of the Digestive System 555-555.9 Regional Enteritis (Crohn's Disease) 560.0-560.9 Intestinal Obstruction 562.1 Diverticulitis of Colon 567-567.9 Peritonitis 569.0-569.9 Other Disorders of Intestine 570-571.9 Liver Diseases and Cirrhosis 572.8 Other Sequela of Chronic Liver Disease 573-573.9 Other Liver Disorders 577-577.9 Pancreas Diseases 578-578.9 Gastrointestinal Hemorrhage 584-584.9 585 586 Acute Renal Failure Chronic Renal Failure Renal Failure, Unspecified Complications of Pregnancy, Childbirth 651 Multiple Gestation Diseases of the Musculoskeletal System and Connective Tissue 730-730.9 Osteomyelitis and/or Periostitis 730-730.10 Chronic Osteomyelitis Congenital Anomalies 747.2 751.6 759-759.9 Aortic Atresia / Stenosis Biliary Atresia Other and Unspecified Congenital Anomalies Conditions Originating in the Perinatal Period 765-765.1 Prematurity 769 Respiratory Distress Syndrome 770.0-770.9 Other Respiratory Conditions of Newborn Injury and Poisoning 800-804.9 Fracture of Skull 805-805.9 Fracture of Vertebral Column 806-806.9 Fracture of Vertebral Column with Spinal Cord Injury 828-828.1 Multiple Fractures 853-854.1 Intracranial Injury 869-869.1 Internal Injury 887-887.7 Traumatic Amputation of Arm and Hand 897-897.7 Traumatic Amputation of Leg 949-949.5 Burns 952-952.9 Spinal Cord Injury Complications peculiar to certain specified conditions V23 Supervision of High Risk Pregnancy V42 - V58.9 Transplants, etc. RL-SL-DISCLOSE-2013 Page 2 of 2 - Incomplete without all pages. Order # 164721 12/06/2012 The ity of Fort =orth Stop -Loss Comparison Summary Proposed Effective Date Policy year end date Covered benefits Annual maximum Lifetime maximum Benefit percentage Commission Plan Mirroring Coordination Claim Basis: Specific Deductible Employee tier/lives Estimated monthly premium ING 4/1/2014 12/31/2014 Med/Rx U nlimited U nlimited 100% None Included 12/9 $1,000,000 Employee Only 6497/$5 Employee & Family mmil $32,485 Estimated policy year premium $292,365 Sun Life 4/1/2014 12/31/2014 Med/Rx U nlimited U nlimited 100% None Included 12/9 $1,000,000 3338/$3.66 3159/$7.95 $37,331 $335,980 Aetna No Bid