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Per the HHS rule governing short term limited duration coverage, short term medical policy purchases are limited to a maximum duration of 90 days. You may be eligible to apply for a new policy after your current policy expires (subject to regulations in certain States).
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Please answer the following medical questions for all individuals, including dependents, applying for coverage
Please be aware that any misstatements and omissions may be a material misrepresentation and a basis for rescission of your coverage. In the event of a rescission; (1) coverage will be void as of the Effective Date; (2) all premiums paid will be refunded; (3) any claims that have been submitted will be denied; (4) if any claims have been paid, the amount of claims paid will be deducted from any premium refund due.
ACCEPTANCE AND ACKNOWLEDGEMENT:
AUTHORIZATION TO RELEASE INFORMATION: I authorize any health care provider, doctor, medical professional, medical facility, insurance company, pharmacy benefit manager, person or organization to release any information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability of employment related information concerning the patient, excluding genetic information, to the insurer or its administrator.
- Any electronic document bearing a user’s e-signature will be considered "in writing" and "wet-signed".
- Any user e-signed document shall be deemed to be an “original” document when printed and used in the normal course of business.
- Absent manifest error, the admissibility, validity, or use of any e-signed electronic document cannot be contested.
Short Term Medical
Review and Acknowledge
Please verify that you accept and understand the terms and disclaimers below, and complete the electronic signature.
eSignature and Submission
It is important that you carefully read and fully understand the following.
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These products are underwritten by Independence American Insurance Company (IAIC)
IAIC Short Term Disclaimers
This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage. Also, this coverage is not “minimum essential coverage.” If you don’t have minimum essential coverage for any month in 2018, you may have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.
This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.
The termination or loss of this policy does not entitle you to a special enrollment period to purchase a health benefit plan that qualifies as minimum essential coverage outside of an open enrollment period. These products may include a pre-existing condition exclusion provision.
This policy has exclusions, limitations, reduction of benefits and terms under which the Policy may be continued in force or discontinued. For costs and complete details of the coverage, call your insurance producer. The policy itself sets forth in detail the rights and obligations of both the policyholder and the insurance company. It is, therefore, important that you READ THE POLICY CAREFULLY. For complete details, refer to the Short Term Medical Expense Insurance Policy Form #IAIC ISTM POL 0913 (Policy number may vary by state).
The quote includes premium, monthly fees and a one-time initial enrollment fee. If for any reason you are not satisfied with this Policy, you may return it to us within 10 days after you receive it. We will refund any premium paid minus the enrollment and administrative fees; your coverage issued under the Policy will be void, as though coverage had not been issued.
The quote shown above is for your requested effective date ONLY. If the actual effective date of your policy is different from the requested effective date, the actual cost of your policy may differ from the quote above.
All applications and policy quotes are subject to final approval by our Policy Administration Department prior to issuance. All quotes shown are estimates ONLY. Premium will not change unless effective date changes or the applicant provides updated information prior to policy issuance. For example, if the applicant selects an optional benefit, that is included in the quote.
If such a cost variance occurs you will be notified of your actual policy cost by our Policy Administration Department prior to issuance.
The application and initial payment must be received by us prior to the requested effective date. If a monthly billing method has been selected, future payments will be due monthly on the billing date.
ENROLLMENT AND MONTHLY FEE DISCLOSURE: A one-time enrollment fee is applied to your initial payment. A separate monthly fee is included in the monthly charge. The enrollment and/or monthly fee will not affect your eligibility for coverage.
These plans are not available in all states and availability in a state is subject to change. If you submit an application for a state where the plan is no longer available, your application and premium (if included) will be returned and coverage will not be effective.
Short Term Medical (STM) is a limited duration medical expense policy and is non-renewable. The amount of benefits provided depends on the plan selected and the premium will vary with the amount of benefits selected. STM is not a replacement for the comprehensive health insurance required under the ACA. This coverage has a pre-existing condition limitation provision.
Non-Renewable – Short-Term Medical is non-renewable. If you purchase a new policy, any conditions for which you incurred claims under the prior policy is considered a pre-existing condition. The purchase of a new policy is not guaranteed and you may be ineligible for new coverage based on pre-existing conditions. The new policy will have a new deductible and coinsurance limit to be satisfied according to the policy documents.
Pre-Existing Condition Limitation – The short-term limited duration medical expense product does not provide portability of prior coverage. Any medical condition or sickness for which medical advice, care, diagnosis, treatment, consultation or medication was recommended or received from a doctor within five years* immediately preceding the covered persons’ effective date of coverage; or symptoms within the five years* immediately prior to the coverage that would cause a reasonable person to seek diagnosis, care or treatment will not be a covered benefit.
*6 months in ID, KY, MI, ND, NH, NM, OH, WA, WY; 12 months in CO, IN, LA, MD, ME, MS, NC, NV, SD, VA; 24 months in CT, FL, IL, UT; or 36 months in MT.
This Plan is underwritten by Independence American Insurance Company (IAIC), a member of the IHC Group. For more information about IAIC and the IHC Group, visit our website at www.ihcgroup.com.
About the IHC Group:
Independence Holding Company (NYSE: IHC), formed in 1980, is a holding company that is principally engaged in underwriting, administering and/or distributing group and individual specialty benefit products, including disability, supplemental health, pet, and group life insurance through its subsidiaries (Independence Holding Company and its subsidiaries collectively referred to as “The IHC Group”). The IHC Group consists of three insurance companies (Standard Security Life Insurance Company of New York, Madison National Life Insurance Company, Inc. and Independence American Insurance Company), and IHC Specialty Benefits, Inc., a technology-driven full-service marketing and distribution company that focuses on small employer and individual consumer products through general agents, telebrokerage, call centers, advisors, private label arrangements, independent agents, and through the following brands: www.HealtheDeals.com; Health eDeals Advisors; Aspira A Mas; www.PetPartners.com; and www.PetPlace.com.
About Independence American Insurance Company:
American Insurance Company is domiciled in Delaware and licensed to write property and/or casualty insurance in all 50 states and the District of Columbia. Its products include short-term medical, hospital indemnity, fixed indemnity limited benefit, group and individual dental, and pet insurance. Independence American is rated A- (Excellent) for financial strength by A.M. Best, a widely recognized rating agency that rates insurance companies on their relative financial strength and ability to meet policyholder obligations (an A++ rating from A.M. Best is its highest rating).
This plan is administered by The Loomis Company acting as a third party (authorized) administrator on behalf of Independence American Insurance Company.
About The Loomis Company
The Loomis Company (Loomis), founded in 1955, has been a leading Third Party Administrator (TPA) since 1978. Loomis has strategically invested in industry leading ERP platforms, and partnered with well-respected companies to enhance and grow product offerings. Loomis supports a wide spectrum of clients from self-funded municipalities, school districts and employer groups, to large fully insured health plans who operate on and off state and federal marketplaces. Through innovation and a progressive business model, Loomis is able to fully support and interface with its clients and carriers to drive maximum efficiencies required in the ever evolving healthcare environment.