Common use of Termination of Coverage Clause in Contracts

Termination of Coverage. Group is liable for Premium payments from the time You cease to be eligible for coverage until the end of the Contract Month in which Group notifies HMO that You are no longer covered by the Group and are not eligible for coverage. Group is required to provide coverage for You until the end of the Contract Month in which the termination notice or other such notice, if any, permitted by applicable law or regulatory guidance, is received by HMO. Subject to the preceding paragraph, coverage of any Member who ceases to be eligible as determined in WHO GETS BENEFITS; Eligibility, will terminate on the last day of the Contract Month in which Group notifies HMO that the Member is no longer eligible for coverage and eligibility ceases unless otherwise specified and agreed upon by the Group and HMO. This paragraph also applies to a Dependent of Subscriber who has lost eligibility, for whatever reason, including the death of Subscriber. If this Certificate is terminated for nonpayment of Premium, Your coverage shall be terminated effective after the last day of the Grace Period. Only Members for whom the stipulated payment is actually received by HMO shall be entitled to health services covered hereunder and then only for the Contract Month for which such payment is received. If any required payment is not received by the Premium due date, then You shall be terminated at the end of the Grace Period. You shall be responsible for the cost of services rendered to You during the Grace Period in the event Premium payments are not made by Group. Your coverage is terminated upon the termination of the Group Agreement. The fact that Group does not notify You of the termination of Your coverage due to the termination of the Group Agreement shall not deem continuation of Your coverage beyond the date coverage terminates. If Your coverage is terminated, Premium payments received on Your account applicable to periods after the effective date of termination shall be refunded to Group within thirty (30) days, and neither HMO nor Participating Providers shall have any further liability under this Certificate. Any claims for refunds by Group must be made within sixty (60) days from the effective day of termination of Your coverage or otherwise such claims shall be deemed waived. Except as expressly provided below and elsewhere in this Certificate and subject to the provisions of COBRA Continuation Coverage, State Continuation Coverage, or Transfer of Residence, HMO may terminate coverage for Group upon sixty (60) days prior written notice.

Termination of Coverage. Group is liable for Premium payments from the time You cease to be eligible for coverage until the end of the Contract Month in which Group notifies HMO that You are no longer covered by the Group and are not eligible for coverage. Group is required to provide coverage for You until the end of the Contract Month in which the termination notice or other such notice, if any, permitted by applicable law or regulatory guidance, is received by HMO. Subject to the preceding paragraph, coverage of any Member who ceases to be eligible as determined in WHO GETS BENEFITS; Eligibility, will terminate on the last day of the Contract Month in which Group notifies the HMO that the Member is no longer eligible for coverage and eligibility ceases unless otherwise specified and agreed upon by the Group and HMO. This paragraph also applies to a Dependent of Subscriber who has lost eligibility, for whatever reason, including the death of Subscriber. If this Certificate is terminated for nonpayment of Premium, Your coverage shall be terminated effective after the last day of the Grace Period. Only Members for whom the stipulated payment is actually received by HMO shall be entitled to health services covered hereunder and then only for the Contract Month for which such payment is received. If any required payment is not received by the Premium due date, then You shall be terminated at the end of the Grace Period. You shall be responsible for the cost of services rendered to You during the Grace Period in the event that Premium payments are not made by Group. Your coverage is terminated upon the termination of the Group Agreement. The fact that Group does not notify You of the termination of Your coverage due to the termination of the Group Agreement shall not deem continuation of Your coverage beyond the date coverage terminates. If Your coverage is terminated, Premium payments received on Your account applicable to periods after the effective date of termination shall be refunded to Group within thirty (30) days, and neither HMO nor Participating Providers shall have any further liability under this Certificate. Any claims for refunds by Group must be made within sixty (60) days from the effective day of termination of Your coverage or otherwise such claims shall be deemed waived. Except as expressly provided below and elsewhere in this Certificate and subject to the provisions of COBRA Continuation Coverage, State Continuation Coverage, or Transfer of Residence, HMO may terminate coverage for Group upon sixty (60) days prior written notice.

Termination of Coverage. Group is liable Your insurance under the policy terminates at the ear- liest time stated below: attainment of age or retirement; termination of the policy; on the premium due date if your employer fails to pay the required premium for Premium payments from you except as the time You result of an inadvertent error; on the date you give notice of cancellation to your employer; if you are insured under the policy as an active employee of your employer, on the date you cease to be associated with your employer in a capacity making you eligible for insurance under the policy. Upon termination of employment or eligibility for any reason, the insurance coverage will be continued until the end of the period for which the premium has been paid. You must send us written notice of a claim within days after the date of loss on which the claim is based. Written proof of your claim must be given to us no later than days after the date of loss. if it is not rea- sonably possible to give written proof in the time re- quired, we shall not reduce or deny the claim for this reason if the proof is filed as soon as is reasonably Benefits will be paid as soon as we receive proof of claim acceptable to us. World i s a d i v i s i o n o f C i r c u i t World C o r p o r a t i o n World Circuit World Corporation Contract Month in which Group notifies HMO that You are no longer covered by the Group and are not eligible for coverageNo. Group is required to provide Table of Contents Table of Contents Who qualifies as your dependent Enrolment When coverage for You until the end begins Changes affecting your coverage Updating your records When coverage ends Replacement coverage claims Proof of disability Coordination of benefits Medical examination overpayments Definitions General description of the Contract Month coverage Deductible Prescriptiondrugs Hospital expenses in which the termination notice your province Expenses out of your province Medical services and equipment Paramedical services Contact lenses or other such notice, if any, permitted by applicable law or regulatory guidance, eyeglasses When coverage ends Payments after coverage ends What is received by HMO. Subject not covered When and how to the preceding paragraph, coverage of any Member who ceases to be eligible as determined in WHO GETS BENEFITS; Eligibility, will terminate on the last day make a claim General description of the coverage Deductible January I Contract Month in which Group notifies HMO that the Member is no longer eligible for coverage and eligibility ceases unless otherwise specified and agreed upon by the Group and HMONo. This paragraph also applies to a Dependent Table of Subscriber who has lost eligibility, for whatever reason, including the death of Subscriber. If this Certificate is terminated for nonpayment of Premium, Your coverage shall be terminated effective after the last day of the Grace Period. Only Members for whom the stipulated payment is actually received by HMO shall be entitled to health services covered hereunder and then only for the Contract Month for which such payment is received. If any required payment is not received by the Premium due date, then You shall be terminated at the end of the Grace Period. You shall be responsible for the cost of services rendered to You during the Grace Period in the event Premium payments are not made by Group. Your coverage is terminated upon the termination of the Group Agreement. The fact that Group does not notify You of the termination of Your coverage due to the termination of the Group Agreement shall not deem continuation of Your coverage beyond the date coverage terminates. If Your coverage is terminated, Premium payments received on Your account applicable to periods after the effective date of termination shall be refunded to Group within thirty (30) days, and neither HMO nor Participating Providers shall have any further liability under this Certificate. Any claims for refunds by Group must be made within sixty (60) days from the effective day of termination of Your coverage or otherwise such claims shall be deemed waived. Except as expressly provided below and elsewhere in this Certificate and subject to the provisions of COBRA Continuation Coverage, State Continuation Coverage, or Transfer of Residence, HMO may terminate coverage for Group upon sixty (60) days prior written notice.Contents

Termination of Coverage. Group is liable for Premium payments (a) An Enrollee's coverage shall be terminated, subject to Department approval, upon the occurrence of any of the following conditions: (1) dismissal from the time You cease Plan by the Contractor for "good cause" shown may only occur upon receipt by the Contractor of written approval of such termination by the Department. The Contractor shall give the Enrollee at least 10 days notice before termination of coverage for "good cause"; except the notice period is shortened to 5 days if probable Enrollee fraud has been verified. For purposes of this paragraph, "good cause" may include, but is not limited to fraud or other misrepresentation by an Enrollee, threats or physical acts constituting battery to the Contractor, the Contractor's personnel or the Contractor's participating Providers and staff, chronic abuse of emergency rooms, theft of property from the Contractor's Affiliated Sites, an Enrollee's sustained noncompliance with the Plan physician's treatment recommendations (excluding preventive care recommendations) after repeated and aggressive outreach attempts are made by the Plan or other acts of an Enrollee presented and documented to the Department by the Contractor which the Department determines constitute "good cause." Termination of coverage shall take effect at 11:59 p.m. on a date specified by the Department, which shall be eligible for coverage until no later than the end first day of the Contract Month in which Group notifies HMO second month after the Department determines that You are "good cause" exists; (2) when the Department determines that the Enrollee no longer covered qualifies as a Potential Enrollee. Termination of coverage shall take effect at 11:59 p.m. on a date specified by the Group and are not eligible for coverage. Group is required to provide coverage for You until Department, which shall be no later than the end first day of the Contract Month in which second month after the termination notice or other such notice, if any, permitted by applicable law or regulatory guidance, Department makes the determination. If the Enrollee is received by HMO. Subject receiving Medical Assistance under Aid to the preceding paragraphAged, Blind and Disabled (AABD), and the Contractor notifies the Department that the Enrollee is receiving Social Security disability benefits (SSI), the disenrollment shall be retroactive to the date of AABD eligibility; (3) upon the Enrollee's death. Termination of coverage of any Member who ceases to be eligible as determined in WHO GETS BENEFITS; Eligibility, will terminate shall take effect at 11:59 p.m. on the last day of the Contract Month month in which Group notifies HMO the Enrollee dies; (4) when an Enrollee elects to terminate coverage by so informing the Contractor or the Department, at the Contractor's Sites, or at such other locations as designated by the Department. Enrollees may elect to disenroll at any time. The Contractor shall comply with any Department policies then in effect to promote and allow interaction between the Contractor and the Enrollee seeking disenrollment prior to the disenrollment. The Contractor shall, within three (3) business days of the request, send to the Enrollee the Managed Care Disenrollment Form, DPA Form 2575B, and shall not delay the provision or processing of this form for the purpose of arranging informational interviews with the Enrollees, or for any other purpose. The Contractor shall forward to the Department information concerning the disenrollment by the end of the fifth (5th) business day following the Contractor's receipt of a completed Managed Care Disenrollment Form. Termination of coverage shall take effect at 11:59 p.m. on a date specified by the Department; which shall be no later than the first day of the second month after the Department is notified of the request for disenrollment. At some point during the term of this Contract, but in no event later than October 16, 2003, the Contractor shall be required to submit all disenrollment information electronically to the Department and retain the original forms for at least six (6) years. The Department shall provide the Contractor with specific file submission requirements; (5) when an Enrollee no longer resides in the Contractor's Contracting Area, unless waiver of this subparagraph is approved in writing by the Department and assented to by the Contractor and Enrollee. If an Enrollee is to be disenrolled at the request of a Contractor, the Contractor first must provide documentation satisfactory to the Department that the Member is Enrollee no longer eligible for coverage and eligibility ceases unless otherwise specified and agreed upon by resides in the Group and HMOContractor's Contracting Area. This paragraph also applies to a Dependent Termination of Subscriber who has lost eligibility, for whatever reason, including the death of Subscriber. If this Certificate is terminated for nonpayment of Premium, Your coverage shall be terminated effective after take effect at 11:59 p.m. on the last day of the Grace Periodmonth prior to the month in which the Department determines that the Enrollee no longer resides in the Contractor's Contracting Area. Only Members for whom This date may be retroactive if the stipulated payment is actually received by HMO Department can determine the month in which the Enrollee moved from the Contractor's Contracting Area; (6) when the Department determines, pursuant to Article IX, that an Enrollee has other significant insurance coverage. The Contractor shall be entitled to health services covered hereunder and then only for the Contract Month for which such payment is received. If any required payment is not received notified by the Premium due dateDepartment of such disenrollment on the monthly Prelisting Report. Termination of coverage shall take effect at 11:59 p.m. on a date specified by the Department. (b) In conjunction with a request by the Contractor to disenroll an Enrollee, then You the Contractor shall be terminated at furnish to the end Department all information requested regarding the basis for disenrollment and all information regarding the utilization of services by that Enrollee. (c) The Contractor shall not seek to terminate Enrollment because of an adverse change in the Enrollee's health status or because of the Grace Period. You shall be responsible for Enrollee's (i) utilization of Covered Services, (ii) diminished mental capacity, (iii) uncooperative/disruptive behavior resulting from such Enrollee's special needs (except to the cost of services rendered to You during the Grace Period extent such Enrollee's continued enrollment in the event Premium payments are not made by GroupPlan seriously impairs the Contractor's ability to furnish Covered Services to the Enrollee or other Enrollees) or (iv) action in connection with exercising his/her Appeal or Grievance rights. Your coverage is terminated upon Such attempts to seek to terminate Enrollment will be considered in violation of the terms of this Contract. (d) Except as otherwise provided in this Article IV, Section 4.6, the termination of this Contract terminates coverage for all persons who become Enrollees under it. Termination of coverage under this provision will take effect at 11:59 p.m. on the Group Agreement. The fact that Group does not notify You last day of the termination of Your last month for which the Contractor receives payment, unless otherwise agreed to, in writing, by the parties to this Contract. (e) Any Enrollee whose coverage due to has been terminated by the termination of the Group Agreement shall not deem continuation of Your coverage beyond Department solely because such Enrollee no longer qualifies as a Potential Enrollee, who subsequently qualifies as a Potential Enrollee within a two (2) month period following the date coverage terminates. If Your coverage is terminatedof termination, Premium payments received on Your account applicable to periods after the effective date of termination shall be refunded to Group within thirty (30) days, and neither HMO nor Participating Providers shall have any further liability under this Certificate. Any claims for refunds by Group must be made within sixty (60) days from automatically re-enrolled with the effective day of termination of Your coverage or otherwise such claims shall be deemed waived. Except as expressly provided below and elsewhere in this Certificate and subject to the provisions of COBRA Continuation Coverage, State Continuation Coverage, or Transfer of Residence, HMO may terminate coverage for Group upon sixty (60) days prior written noticeContractor.

Termination of Coverage. Group is liable for Premium payments from the time You cease to be eligible for coverage until the end Coverage of a Member or Members under this Contract will terminate under any of the Contract Month following conditions, and termination will be effective on the date indicated, subject to the conversion privilege in which Group notifies HMO Section VIII of this Contract, when applicable: A. In the event that You a Subscriber ceases to meet the eligibility requirements of Section IV.A of this Contract, coverage of Subscriber and Subscriber's Dependents who are no longer covered by the Group and are not eligible for coverage. Group is required to provide coverage for You until the end of the Contract Month in which the termination notice or other such noticeMembers, if any, permitted by applicable law or regulatory guidance, is received by HMO. Subject to the preceding paragraph, coverage of any Member who ceases to be eligible as determined in WHO GETS BENEFITS; Eligibility, will terminate on the last day next premium due date following the date on which the Subscriber ceased to meet the eligibility requirements. B. In the event that a Subscriber's Dependent who is a Member pursuant to this Contract ceases to meet the eligibility requirements of Section IV.B of this Contract, coverage of such Dependent will cease on the next premium due date following the date on which the Dependent ceased to meet the eligibility requirements of Section IV.B. C. In the event that Group coverage under this Contract Month terminates pursuant to Section XII, coverage of all Members under this Contract will terminate as provided in which Group notifies HMO Section XII. D. In the event that the Member is no longer eligible for Subscriber or Subscriber's Dependents who are Members pursuant to this Contract, if any, fails to make any contribution or copayment required under this Contract, coverage and eligibility ceases unless otherwise specified and agreed upon by the Group and HMO. This paragraph also applies to a Dependent of Subscriber who has lost eligibilityand Subscriber's Dependents, for whatever reasonif any, including will terminate thirty (30) days after written notice is given to the death Subscriber and Contract Holder by HMO of Subscribersuch failure. If this Certificate is terminated for nonpayment At the effective date of Premiumsuch termination, Your coverage shall be terminated effective after the last day of the Grace Period. Only Members for whom the stipulated payment is actually prepayments received by HMO shall be entitled to health services covered hereunder and then only on account of such terminated Member or Members for the Contract Month for which such payment is received. If any required payment is not received by the Premium due date, then You shall be terminated at the end of the Grace Period. You shall be responsible for the cost of services rendered to You during the Grace Period in the event Premium payments are not made by Group. Your coverage is terminated upon the termination of the Group Agreement. The fact that Group does not notify You of the termination of Your coverage due to the termination of the Group Agreement shall not deem continuation of Your coverage beyond the date coverage terminates. If Your coverage is terminated, Premium payments received on Your account applicable to periods after the effective date of termination shall be refunded to Contract Holder, and HMO shall have no further liability or responsibility with respect to such Member or Members under this Contract. E. In the event that a Subscriber becomes covered under an alternative health benefit plan or under any other plan which is offered by, through or in connection with the Group within in lieu of coverage under this Contract, coverage of Subscriber and Subscriber's Dependents who are Members pursuant to this Contract. if any, will terminate under this Contract, effective the date alternate coverage begins. F. In the event that a Member acts fraudulently or makes a material misrepresentation in applying for or obtaining coverage or benefits under this Contract, or misuses the HMO Identification Card, including but not limited to allowing or assisting a person other than the Member named on the Identification Card to obtain HMO benefits, Member's coverage under this Contract shall be terminated effective immediately upon written notice. In the absence of fraud or material misrepresentation, all statements made by any Member or any person applying for coverage under the Contract will be deemed representations and not warranties. No statement made for the purpose of obtaining coverage will result in the termination of coverage or reduction of benefits unless the statement is contained in writing and signed by the Member, and a copy of same has been furnished to Member prior to termination. G. In the event a Member refuses upon request to cooperate and provide any facts necessary for HMO to administer its Coordination of Benefits or recovery provisions set forth herein, the coverage of such Member may be terminated upon thirty (30) days written notice by the HMO. H. In the event that HMO or Participating Providers, after reasonable efforts, are unable to establish and maintain what it and Member agree to be a satisfactory relationship with each other, then the rights of such Member under this Contract may be terminated on not less than thirty (30) days' written notice to Member and Contract Holder, and neither HMO nor Participating Providers shall have any further liability under this Certificate. Any claims for refunds by Group must be made within sixty (60) days from the effective day of termination of Your coverage or otherwise such claims shall be deemed waived. Except as expressly provided below and elsewhere in this Certificate and subject to the provisions Grievance Procedure described in Section IX.M. At the effective date of COBRA Continuation Coveragesuch termination, State Continuation Coverageprepayments received on account of such terminated Member or Members for periods after the effective date of termination shall be refunded to the Contract Holder, and HMO shall have no further liability or Transfer responsibility under this Contract with respect to such Member or Members. I. In the event the coverage of Residencea Subscriber terminates for any reason listed in this Section, HMO may terminate coverage for Group upon sixty (60) days prior written noticeof Subscriber's dependents who are Members pursuant to this Contract, if any, will also terminate.

Termination of Coverage. Group is liable for Premium payments from Subject to certain exceptions: o Your coverage under the time You cease to be eligible for coverage until Policy ends immediately when you leave the end employment of the Contract Month in which Group notifies HMO that You are Policyholder. It also ends if such employee is no longer covered by eligible under the Group and Policy, the Policy is discontinued or, after a grace period, premiums are not paid. o Coverage for your dependents end when they no longer meet the definition of dependents under the Policy or your coverage under the Policy terminates. o If coverage under the Policy terminates and you want to continue your medical coverage and that of your eligible dependents, you may apply for coverage. Group is required to provide continued coverage for You until the end under COBRA or convert your coverage into an individual policy, as explained in Article IX of the Contract Month Policy. CLAIMS APPEAL PROCEDURE - If your claim has been denied in whole or in part, you will be notified by CHI. This notice will set forth the reasons for such denial. If you wish to appeal this decision, you may write to the address which appears on the termination notice or other such notice(to the attention of the person who signed the letter, if any). It is important for you to understand the reasons for the denial of benefits in order to decide whether you want to appeal and request that the claim be reviewed again. You should examine this Summary of Benefits and the Policy, which are on file with your employer. The Policy is a legal document setting forth the full terms and conditions of your hospital and professional coverages and excluded services. You may also request a fuller explanation of the rejection decision by calling CHI. You ma▇ ▇▇▇▇al a denial of benefits within 30 days of the date ▇▇ the rejection by sending a letter stating why you think your claim should not have been denied, including a copy of the denial letter and with any additional claim. Be sure to include in your letter your Policy number, your Policyholder number, claim number, if any, permitted by applicable law or regulatory guidance, is received by HMO. Subject to your employer's name and the preceding paragraph, coverage date of any Member who ceases to be eligible as determined in WHO GETS BENEFITS; Eligibility, will terminate on the last day of the Contract Month in services for which Group notifies HMO that the Member is no longer eligible for coverage and eligibility ceases unless otherwise specified and agreed upon by the Group and HMO. This paragraph also applies to a Dependent of Subscriber who has lost eligibility, for whatever reason, including the death of Subscriberbenefits were denied. If this Certificate is terminated for nonpayment of Premium, Your coverage shall be terminated effective after the last day of the Grace Period. Only Members for whom the stipulated payment is actually received by HMO shall be entitled to health services covered hereunder and then only for the Contract Month for which such payment is received. If any required payment is you do not received by the Premium due date, then You shall be terminated at the end of the Grace Period. You shall be responsible for the cost of services rendered to You during the Grace Period in the event Premium payments are not made by Group. Your coverage is terminated upon the termination of the Group Agreement. The fact that Group does not notify You of the termination of Your coverage due to the termination of the Group Agreement shall not deem continuation of Your coverage beyond the date coverage terminates. If Your coverage is terminated, Premium payments received on Your account applicable to periods after the effective date of termination shall be refunded to Group appeal within thirty (30) days, the denial will become final and neither incontestable. Upon receipt of your letter and any additional information you provide, your records will be reviewed; and the results of this review will be sent to you promptly. In unusual cases, as when review of your claim requires examination by medical personnel, including consulting physicians, the review may be extended. No legal action at law or equity may be brought to recover any benefits under the Policy unless and until the appeal process set forth above has been exhausted, and in no event prior to the expiration of 60 days after notice of claim has been furnished to CHI in accordance with the requirements of the Policy. UNITED STATES HEALTH CARE SYSTEMS OF PENNSYLVANIA, INC., d/b/a THE HEALTH MAINTENANCE ORGANIZATION OF PENNSYLVANIA d/b/a U.S. HEALTHCARE FLEX OPTION PLAN DURABLE MEDICAL EQUIPMENT RIDER United States Health Care Systems, Inc. d/b/a The Health Maintenance Organization of Pennsylvania, Inc. d.b.a. U.S. Healthcare ("HMO") and Contract Holder agree to offer to the HMO nor Participating Providers shall have any further liability under this Certificate. Any claims for refunds by Group must be made within sixty (60) days from Members the effective day of termination of Your coverage or otherwise such claims shall be deemed waived. Except as expressly provided below and elsewhere in this Certificate and following benefit subject to the provisions listed hereunder: Durable medical equipment will be provided when medically necessary and required for therapeutic use as determined by HMO. The wide variety and continuing development of COBRA Continuation Coveragepatient care equipment makes it impractical to provide a complete listing, State Continuation Coveragetherefore, the HMO Medical Director must approve requests on a case-by-case basis. HMO reserves the right to provide the most cost efficient and least restrictive level of service or Transfer of Residenceitem which can be safely and effectively provided. Instruction and appropriate services required for the Member to properly use the item, HMO may terminate such as attachment or insertion, is also covered. Replacement, repairs and maintenance not provided for under a manufacturer's warranty or purchase agreement coverage for Group upon sixty (60) days prior written notice.will be a covered benefit when it is functionally necessary and appropriate. General guidelines considered are: