Arizona Health Insurance > Golden Rule Insurance Company > Plan Provisions

Provisions That Apply to All Plans

This information is only a general outline of the coverage provisions.  It is not an insurance contract, nor part of the insurance policy or certificate.  You'll find complete coverage details in the policy and certificates.  In most cases, coverage will be determined by the master policy issued in Illinois and subject to Illinois law.

Health-Care Provider Networks
Choosing a Preferred network offers you a significant premium discount, and in most cases, an extensive network of doctors and hospitals.*  Otherwise, Golden Rule health insurance plans include access to one of our savings-based networks.

Transplant Expense Benefit

The following types of transplants are eligible for coverage under the Medical Benefits provision:
Cornea transplants, artery or vein grafts, health valve grafts, and prosthetic tissue replacement, including joint replacements and implantable prosthetic lenses, in connection with cataracts.

Transplants eligible for coverage under the Transplant Expense Benefit are:
Heart, lung, heart and lung, kidney, liver, and bone marrow transplants.

Golden Rule has arranged for certain hospitals around the country (referred to as our "Centers of Excellence") to perform specified transplant services.  If you use one of our "Centers of Excellence", the specified transplant will be considered the same as any other illness and will include a transportation and lodging incentive (for a family member) of up to $5,000.  Otherwise, the acquisition cost for the organ or bone marrow will not be covered, and the covered expenses related to the transplant will be limited to $100,000 and one transplant in a 12-month period.

To qualify as a covered expense under the Transplant Expense Benefit, the covered person must be a good candidate, and the transplant must not be experimental or investigational.  In considering these issues, we consult doctors with expertise in the type of transplant proposed.

The following conditions are eligible for bone marrow transplant coverage:
Allogenic bone marrow transplants (BMT) for treatment of:  Hodgkin's lymphoma or a non-Hodgkin's lymphoma, sever aplastic anemia, acute lymphocytic and nonlymphocytic leukemia, chronic myelogenous leukemia, severe combined immunodeficiency, Stage III or IV neuroblastoma, myelodysplastic syndrome, Wiskott-Aldrich syndrome, thalassemia major, multiple myeloma, Fanconi's anemia, malignant histiocytic disorders, and juvenile myelomonocytic leukemia.

Autologous bone marrow transplants (ABMT) for treatment of:  Hodgkin's lymphoma, non-Hodgkin's lymphoma, acute lymphocytic and nonlymphocyctic leukemia, multiple myeloma, testicular cancer, Stage III of IV neuroblastoma, pediatric Ewing's sarcoma and related primitive neuroectodermal tumors, Wilms' tumor, rhabdomyosarcoma, medulloblastoma, astrocytoma, and glioma.

Notification Requirements

You must notify us by phone on or before the day a covered person:

• Begins the fourth day of an inpatient hospitalization; or
• is evaluated for an organ or tissue transplant.

Failure to comply with the Notification Requirements will result in a 20% reduction in benefits, to a maximum of $1,000.

If it is impossible for you to notify us due to emergency inpatient hospital admission, you must contact us as soon as reasonably possible.

Our receipt of notification does not guarantee either payment of benefits or the amount of benefits.  Eligibility for and payment of benefits are subject to all terms and conditions of the policy.  You may contact Golden Rule for further review if coverage for a health-care service is denied, reduced or terminated.

Preexisting Conditions

Preexisting conditions will not be covered during the first 12 months after an individual becomes a covered person.  This exclusion will not apply to conditions that are both: (a) fully disclosed to Golden Rule in the individual's application; and (b) not excluded or limited by our underwriters.

A preexisting condition is an injury or illness: (a) for which a covered person received medical advice or treatment within 24 months prior to the applicable effective date for coverage of the illness or injury; or (b) which manifested symptoms which would cause an ordinarily prudent person to seek diagnosis or treatment within 12 months prior to the applicable effective date for coverage of the illness or injury.

Limited Exclusion for AIDS or HIV-Related Disease

AIDS or HIV-related disease are treated the same as any other illness unless the onset of AIDS or HIV-related disease is:  (a) diagnosed before the coverage has been in force for one year;, or (b) first manifested before the coverage has been in force for one year.  If diagnosed or first manifested before coverage has been in force for one year, AIDS or HIV-related disease claims will never be covered.  Details of the limited exclusion are set forth in the policy and certificates.

*Using UnitedHealthcare Choice Plus network, available in most areas.