Document mppx1LE8ry6xqjX3D8jLBnRbb

iloywri *9 roller le. 8577-0 RATBESTCS-MAHgATTAy. UK. Effect!ve Date of Ridor: ,Jbd** 25 1968 (BIDV SVP1DCHIAI, MEOZCAZ. SXFER9S XKSURAflCt RIDER Personal aad Dependant Benefits Issued By HETROPQLXTAK LITE IKSURAHCE COMPANY (Herein called the lacunae* Coapaay) Iaauraae* la provided toy tAla Rider ealy vith respect to Bnloyce Dependents la ths following classes who have to*eoae eligible for any coverage r the Act (aa her*laaftr defined) aad with respect to whoa iaauraae* would otheri to* provided under tb* Medical Etpenae laauranc* - attended Coverage provisions of Croup Polley if they had aot tooeoae eligible for coverage under said Aeti Enploysea of Maabattaa Rubber Division at Facade, Rev Jersey, aad Dependents of aucb teployec* Beetioo R-l. Definitions.-- "Act" neana Title XVXZX of the Boelal Security Act of tto* United 8tat*a aa ted or thereafter aaended. " Medical Prpenae Iaauraae* - Beheaded Coverage proriaiona of the Group Polley", *d to thla Rider, r*fra to Medical Stpenaa Iaauraae* attended Coverage Suroleaien- Agreeaent Pore G.&Z97. "Roo-oeeupatioaal injury" aaaaa aay injury aot arialag out of or in the -#* of aay eaployaeat for wag* or profit. *Koo-occupational ai-kneaa" aaaaa aay slekncaa aot entitling the person who contracted the sickness to benefits under aay vortaen'a coaqpenaatloe or occupational ase lav. "Spoil* of Xllaess" has the sealng epeclfled therefor in the Act. "Extended Ohm facility" has the neaalng epeeified therefor in the Aot. "Pbyeleian" or "surgeon" a person logally licensed to practice nedieloe action -2. Benefit yronics. ~ (A) ZXSURXKG CLAUSE.--If aa Employee or Dependent, while insurance ea hie aeeount la la effect hereunder, incur* Covered Medical Expenses ee a result of aen.oeeqaatlonal ln.lurr or non-occuaatioaal sickness, the laauraaee Coapaoy ahall pay, aubjeet to the teraa and limitations hereof, benefits la an aseunt equal to the appll* cable Insured Proportion of the aaouat by which aueh expeaeea incurred oe account of the ihroiowee or on aeeount of the Dependent during a calendar year ezeeed the applicable Deductible Aaouat. (1) She aggregate of the payments hereunder for all Covered Medical Expenses Incurred on eeeouat of an Employee or a Dependent ahall not exceed the Maxima Aggregate Benefit applicable to such araloyce or Dependent. If, at nay tine after benefita Of at leant 11,000 have been paidTor Covered Medical Expenses incurred on aeeount of an Bmployee or a Dependaat, the Employee submits at hie own arpenae evidence, aatlafaetory to tho Znauranea Company, of the Insurability of the person on whose account aueh aaouat of benefita waa paid, the aaouat of benefita paid for aueh expeaeea Incurred prior to the date ea of ifeleb aueh evidence la eubaltted ahall be disregarded in any subsequent application of the provisions of tho preceding eeatoaoe, of this sentence, end ef itaa (2) of this subsection (A). (2) The Supplemental Medical Expense insurance on account of an Employee or a Dependent ahall automatically cease on the data aa of which Covered Medical Expenses are in* curred on account of aueh Eaployee or Dependent in an aaount such that the total payment for such expeaaaa shall equal the Maximise Aggregate Benefit applicable to uch person. The Supplemental Medical fiepense Znauranea on acoouat of any such peraoa aay be reinstated only if the tonloywe submits at hla own expanse evidence of la* eurablllty of such person aatlafaetory to the Znauranea Oompaay. She data on which a aarrloa la received or rendered will be considered the data on which aay expanse for euch aarrlea is incurred. (B) COVBtED MEDICAL EXPENSES.--"Covered Medical Expenses" --na the following expenses for aedlcal services idiicfa tn rendered for tramtaeat of inury or sickness and idileb an perfoned or pnserlbed by a physician or surgeon, bat only to the extant that auch expenses ara naconabla,* necessary and euatnaary: (1) fieponses for private-duty aervleaa of a registered graduate nurse, or of a licensed practical nurse If a registered graduate nurse la not available, other than a nurse tfeo ordinarily resides in the taployee's booe or ubo is a Maher of tbs Bsployee1 a imedlate ftally. (2) expenses for drugs and aedlelnes dlapcsaad by a licensed pbaraaelst on a physician's proscription other than (a) Shoes provided by a hospital or firtended Care facility. (b) Shoos vtleb cannot be aelf-adalnlaterad and idtleb ara furnlahed as an incident to professional aervleaa of a physician or surgeon. fon 0.933* 9 (13) (C) ixctaiao.-- following txjMBiei are not Covered Medical Expenses: (*) bqptaMa for wnleii n&ieni to an itanlovec or Dependent prior to the date the laaurmaee hereunder becoaea effective with reapeet to aueh Baployee or Dependent. (b) tepensea for aerrleea la connection with eoaaetle surgery or treatnent except that expeneea for aueh eenrleea required for correction of dosage eauaed by accidental injury euetal&ed by the Baployee or pnnnnd- eot while lnauranee la in force on hla aceount~ahaii not be excluded If they othcrvlM qualify aa Covered Medical Cxpenaea. (c) Expenses for aerricee received aa reault of injury or alekaeaa due to aa act of ir, declared or undeclared, tmlcaa aueh met occurred prior ta the effective date of the Medical Expense lnauranee - Extended Coverage provieIona of the Croup Policy. (d) Expenses which oelther the legal obligation to pay. ftmlovee aor the Depeadeot lncura a (e) Bxpenaea to the extent of bcnefltc or aerrleea otbervlae provided under the Oroup Policy or under any other hoapltal. surgical or oedlcal group lnauranee or group prepayntent plan. (f) Cxpenaea for any aervleea to the extent that benefit! ore available under the Act, under any plan or prograa established purauant to the lawn or rcgulatlona of any government, or under any plan or prograa la which any government participate! other than aa aa employer. Any bencflto hereunder will be computed in accordance with the provialona hereof taxing Into account only that part of the cxpenaea for aueh eonflnuent or aerrleea for which beacflta arc not available in any fora under aueh Act, plan or program. In the eaae of any peraon who la not earollad for all coverage for which he haa becoae eligible under aueh Act, plan or prograa, beacflta available will aevertbeleea Include all benefit* to which he would bo entitled If be were enrolled for all ouch coverage. "Any government" lncludea the federal, atate, provincial, or local goveraaent or any political aubdinaloo thereof of the United State# or any other country. This paragraph doea not apply to any such plan or prograa which requires that insurance benefit* be utilised before any benefit* are available thereunder. ? benefit* have been paid hereunder ee account of aervleea received by the toployec ______ or by a Dependent aad thereafter it Is established that the charge* for auch aerv- :e# were not paid by th* Banlovoe or th* Dependent, or said Ehnloycc ' Dependent waa otherwise relhburaed there'for, the Insurance Oe^any shall be entitled ' a refund of the oanuafe of tha benefits paid which is In axeesa of the benefits that <uld have been payable based on tbs netual charges incurred and paid by the Bsolovee _____ or the Dependant* O.MJU 0*> (D) SESUCTXSU AM3URT.--lfce Deductible Aaount for Cowered Medical Expense! la. rerred during eaeh calendar year eball be tbe aaount applicable la accordance with eublection (X) of tbia Section. If aa a result of oae accident, an *>clovec aad hie Dependent incur teverad Medical bepeoeea, tbe Deductible Aaount* tor aueb Covered Medical Xxpeneea la- mrred during tbe calendar year la which tbe aeeident oeeura eball not exceed tbe amount! eoeelfled aa the Dedactlble Anounte for tbe Bnployee. Corered Medical Sxpeaaes incurred on account of an Banlovee or a Depend ent durlac tbe laat three aoathe of a calendar year that are applied to alf"or part of tbe deductible Aaount for that calendar year, eball alee be applied to tbe Deductible Aaount * aeeouat of aucb pereoe for tbe next calendar year* (X) XCBXDULX or SBURAira AXD XSXTZAZ. TOBOW MZBS> -- Xeneflte teployee end each Dependent Deductible Aaount $100 Zneured Proportion to* Mariam Aggregate Benefit for one Medical tzpesjc Period $5,000.00 Mariam Aggregate Benefit $10,000.00 Initial Monthly fralie Batee aeb aeb Bcployee Dependent 2.25 2.25 mi 0.933k (15) V Section R-3. Payment of Claim.-- AU benefits provided la this Rider be paid to the Bsployee ms they accrue upoo receipt of writtea proof that the udleal expenses ror w&ich ciaia Is mde were actually incurred on the date* specified aad that the services were recom mended aad approved by a physician or surgeon. Such proof sust be furnished to the Insurance Company not later than ninety days after the end of the calendar year in which such medical expenses were incurred. Failure to furnish such proof within the tine provided la this Rider shall not invalidate or reduce any if it shall be shown not to haw been reasonably possible to furnish such proof aad that such proof was furnished as soon as reasonably posalble. action K-l. Covered Medical Expense* Incurred after Ceaaatloa of Insurance.-. If an Bsployoe or Dependent, at the date of the cessation of the Supplemental Medical Expense Insurance on his account, is totally disabled as a result of injury or sickness aad, Ails still so totally diaablsd aad within the calendar year in Alcfa such cessation occurs or the calendar year alter such cessation, incurs Covered Medical Expanses, the aanloyee will be"entitled to whatever benefits would have been payable hereunder in eoaacqucaee of such expenses had eueh insurance continued in fores without change to the date such expenses are incurred Section H-5. Coaputetion and Payment of Premiums.-- During the period this Rider is in effeet, premiums based upon the rates then in effect as to the insurance provided hereunder, are due at the ssm time, are payable in the same manner, and are subject to the earns conditions as the premiums for the Medical ftepense Insurance - Extended Coverage under the Croup Policy. Seetioo -6. Addltlooal Provisions.-- Shis Rider is attached to and made part of amid Croup Policy as of the effective date of the Rider indicated om the first page hereof. The Medical fttpenac Insurance - attended Coverage provisions of the Croup Policy apply to the insurance provided ueder this Rider except as any he specifically provided otherwise by the preceding provisions of this Aider aad except that the insurance elause aad provisions regarding benefits which are applicable to the Medical Ecpense Insurance ficteaded Coverage under the 0ro<9 Policy shall mot apply to Insurance provided by this Aider. XH Tr---- VSEREOF, Metropolitan Life Insurance Coapeny bM eaused this Rider to be executed to take offset aa of the effective date of the Rider Indicated oo the first page hereof. JtoascZ. ftiz&JkcJi 04*2 Perm 0.933** * {*6)