• Important Information
• What is Short Term Medical Insurance?
• Eligibility Requirements
• Covered Medical Expense Highlights
• Plan Limitation & Exclusion Highlights
• Coverage Termination Date
• Extension of Benefits After Termination
• Renewability
• Payment Options & Methods
• Money Back Guarantee

Important Information
This plan of Short Term Medical Insurance (insured by Fairmont Specialty) does not provide benefits for pre-existing conditions, work related illnesses and injuries, and preventive care (see Plan Limitation & Exclusion Highlights). If you or a dependent (spouse and/or child) have an existing health condition, please consult with your licensed, independent health insurance agent prior to changing or purchasing health/medical insurance coverage.

Any false statement, material misstatement or omission of information on the application form will be considered a misrepresentation and may be the basis of claim denial or later rescission of coverage issued on the basis of the information given. Such claim denial or rescission and termination of coverage will apply to the Named Insured and his/her covered Dependents without liability to Fairmont Specialty.

Insurance fraud is a crime.  Any person who, with intent to defraud or knowingly facilitates a fraud against an insurer, submits an application or files a claim containing false, deceptive and/or incomplete information is subject to civil and criminal prosecution.

What is Short Term Medical Insurance?
According to a 08/2005 U.S. Department of Commerce report*, 45.8 million Americans are without health insurance coverage.  Don't risk being a statistic - without health insurance coverage, an unexpected illness or injury could be financially devastating! 

* U.S. Census Bureau / U.S. Department of Commerce / Economics and Statistics Administration

The American Health Shield - Short Term Medical is a quality, affordable plan of temporary medical insurance designed specifically for people who are temporarily without health insurance.  This plan offers coverage from 30-days to 180-days or up to 12-months in most states that can become effective as early as tomorrow and be paid for in one single payment or easy monthly installments.

Ideal protection for persons:

• Between jobs, laid off, on strike
• Attending school or recently graduated
• Employed part-time or temporarily
• Waiting for permanent health insurance to begin
• Temporarily without health insurance for most any reason

American Health Shield - Short Term Medical is not an HMO or PPO plan.  In the event of an illness or injury, and you may receive treatment from any licensed healthcare provider or facility anywhere in the U.S.

Eligibility Requirements

Who is eligible to apply for the American Health Shield - Short Term Medical:

• You and your spouse, age 18 to 64 and 11 months, and your unmarried dependent children age 15 days through 18 (24, if a full-time student) that live with you.

To be considered for coverage, persons listed on the application form must:

• be a US citizen (or permanent resident for the past 12 months) and have a Social Security Number;
• not be traveling outside the U.S.;
• live in a state where this plan of insurance is available;
• not be covered by major medical, group health, hospital, governmental, or other medical insurance coverage that will not terminate prior to the Effective Date of this plan;
• not be pregnant or the expectant father of an unborn child;
• not have been declined for health insurance within the past 12 months or received consultation or treatment (within the past 5 years) for any condition identified on the application form;
• not participate in hazardous activities or sports.

Child only coverage is available for your eligible, unmarried dependent child (age 2 through 18) that live with you.  Enter the oldest child as the applicant, and all other child(ren) as dependents.  Child(ren) only applications must be signed by a parent or legal guardian, then mail or fax all pages of the completed application to:

CBPI - Short Term Medical Department
PO Box 20594
Tampa, FL 33622-0594
1-727-799-9093 (Facsimile)

Covered Medical Expense Highlights
The American Health Shield - Short Term Medical provides benefits for Covered Medical Expenses related to covered Injury or Sickness, which are:  1) not in excess of Usual and Customary Charges; 2) not in excess of a maximum benefit amount; 3) made for services and supplies which are a Medical Necessity and listed as Covered Medical Expenses in the Policy or Certificate issued by Fairmont Specialty.

• Hospital Charges: average semi-private room rate, medical care and treatment
• Surgery in a Hospital or Ambulatory Surgical Center
• Physician Services for diagnosis, treatment and surgery
• Intensive Care: up to three times the average semi-private room rate
• Skilled Nursing Facility: up to $30 per day for 30 days
• X-Ray Exams, Laboratory tests and analyses
• X-Ray and Radioactive isotope therapy, anesthesia, oxygen, casts, splints, crutches, braces, surgical dressings, artificial limbs or eyes, rental of medical supplies
• Blood or blood plazma and their administration
• Ambulance Services: $250 per emergency
• Organ Transplants: $50,000 lifetime maximum
• Acquired Immune Deficiency Syndrome (AIDS): $10,000 lifetime maximum
• Home Health Care: up to 40 visits
• Hospice Care: up to $5,000
• Spinal Manipulation/Adjustment: up to $1,000
• Mammography, pap smear and screens
• Gallbladder Surgery: up to a $2,500 lifetime maximum
• Knee injury or disorder: up to a $2,500 lifetime maximum for both left and right knees

Usual and Customary Charges means the lesser of: 1) the actual charge; 2) what the provider would charge for the same service or supply in the absence of insurance; or 3) the reasonable charge as determined by Fairmont Specialty, based on factors such as: a) the most common charge for the same or comparable service or supply in a community similar to where the service or supply is furnished; b) the amount of resources expended to deliver the treatment rendered; c) charging protocols and billing practices generally accepted by the medical community or specialty groups; or d) inflation trends by geographic region.

Pre-Admission Certification: This plan requires a Pre-Admission Certification by a Professional Review Organization prior to in-patient Hospitalization or surgery.  A Covered Person or their Attending Physician must call the Professional Review Organization: 1. For elective or non-emergency Hospitalization or surgery, at least 10-days prior to the date of proposed Hospitalization; 2. Within 48-hours of an emergency admission; or 3. Within 48-hours of delivery for complicated childbirth.  Non-compliance with the Pre-Admission Certification procedure will result in a reduction in benefits of 50%, unless the Covered Person is incapacitated and unable to contact the Professional Review Organization. In such cases, the Covered Person must contact us as soon as possible.

Covered Medical Expenses and Benefits vary by state. Detailed information about these and additional Covered Medical Expenses is listed in the Policy or Certificate issued by Fairmont Specialty to approved applicants.

Limitation & Exclusion Highlights
Unless specifically listed as a Covered Expense in the Policy or Certificate (or as may be provided by an Endorsement attached to the Policy or Certificate), no benefit will be paid for loss or expense caused by, contribution to, or resulting from:

1. Preexisting Conditions, defined as any medical condition or Sickness for which: a) Medical advice, care, diagnosis, treatment, or Consultation was recommended by or received from a Doctor within the 5-years immediately prior to a Covered Person's Effective Date of coverage; or b) Symptoms existed within the 5-years immediately prior to the Covered Persons Effective Date of coverage which would cause a reasonable person to seek diagnosis, care or treatment. “Consultation” means evaluation, diagnosis, or medical advice was given with or without the necessity of a personal examination or visit.; 2. Expenses incurred prior to the Effective Date of a Covered Person’s coverage or incurred after the Expiration Date, regardless of when the condition originated, except in accordance with the Extension of Benefits provision; 3. Expenses to treat complications resulting from treatment or conditions which are not covered; 4. Experimental or Investigative services or treatment.  “Experimental or Investigative” means services, supplies, devices, treatments, procedures, or drugs that have not been recognized as generally-accepted medical treatments. Our determination of what constitutes Experimental or Investigative treatment will be based on, but not limited to, the approval of treatments from the American Medical Association, the U.S. Food and Drug Administration, and the Administrative Procedure Act. Experimental or Investigative includes treatments that have not been demonstrated through sufficient peer-reviewed medical literature to be safe and effective for the proposed use; 5. Expenses for purposes determined by us to be educational; 6. Amounts in excess of the Usual, Reasonable and Customary charges made for covered services or supplies; 7. Expenses you or your Covered Dependent are not required to pay, or which would not have been billed, if no insurance existed; 8. Expenses to the extent that they are paid or payable under other valid and collectible group insurance or medical prepayment plan; 9. Charges that are eligible for payment by Medicare or any other government program except Medicaid; 10. Costs for care in government institutions unless you or your Covered Dependent are obligated to pay for  such care; 11. Expenses for which benefits are received under workers’ compensation or employers’ liability laws; 12. Medical expenses which are payable under any automobile insurance policy without regard to fault (does not apply in any state where prohibited); 13. Charges incurred by a Covered Person while on active duty in the armed forces. Upon written notice to us of entry into such active duty, the unused premium will be returned to you on a pro-rated basis; 14. Expenses resulting from a declared or undeclared war, or from voluntary participation in a riot or insurrection; 15. Expenses incurred while engaging in an illegal act or occupation or during the commission, or the attempted commission, of a felony or assault; 16. Expenses for the treatment of normal pregnancy or childbirth, except for Complications of Pregnancy; 17. Charges for a Covered Dependent who is a newborn child not yet discharged from the Hospital, unless the charges are Medically Necessary to treat premature birth, congenital Injury or Sickness, or Sickness or Injury sustained during or after birth; 18. Charges for voluntary termination of normal pregnancy, normal childbirth or elective cesarean section; 19. The cost of any drug, including birth control pills, supply, treatment or procedure that prevents conception or childbirth; 20. Expenses for the diagnosis and treatment of infertility, including but not limited to any attempt to induce fertilization by any method, invitro fertilization, artificial insemination or similar procedures, whether the Covered Person is a donor, recipient or surrogate; 21. Expenses for sterilization or reversal of sterilization; <?b?ONT>22. Services, supplies or treatment related to sex transformation or sex dysfunction or inadequacies; 23. Costs for physical exams or other services not needed for medical treatment, except as specifically covered; 24. Expenses for prophylactic treatment, including surgery or diagnostic testing, except as specifically covered; 25. Expenses for the treatment of Mental Illness or Nervous Disorders, including, but not limited to, neurosis, psychoneurosis, psychopathy, psychosis, attention deficit disorder, autism, hyperactivity, or mental or emotional disease or disorder of any kind, unless specifically covered; 26. The costs of treatment of alcoholism or alcohol abuse, chemical dependency, substance abuse or drug addiction, unless specifically covered; 27. Expenses incurred for the treatment of Injury or Sickness occurring while intoxicated or under the influence of illegal drugs or hallucinogenic's, except as specifically covered.  “Intoxicated” will have the meaning determined by the laws in the jurisdiction of the geographical area where either the loss or its cause occurs; 28. Expenses incurred in the treatment of Injury or Sickness sustained by voluntary use of alcohol, illegal drugs or hallucinogenic's; 29. The cost of programs, treatment, or procedures for tobacco use cessation; 30. Expenses resulting from suicide or attempted suicide or intentionally self-inflicted Injury, whether while sane or insane (only while sane in Missouri); 31. The cost of dental treatment or care or orthodontia or other treatment involving the teeth or supporting structures, except as specifically covered; 32. Expenses incurred in the treatment by any method for jaw joint problems including temporomandibular joint dysfunction (TMJ), TMJ pain syndromes, craniomandibular disorders, myofacial pain dysfunction, other conditions of the joint linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the joint; 33. Expenses of radial keratotomy or correction of refractive error, eye refractions, vision therapy, routine vision exams to assess the initial need for, or changes to prescription eyeglasses or contact lenses, the purchase, fitting or adjustment of eyeglasses or contact lenses, or treatment of cataracts; 34. The costs for routine hearing exams to assess the need for or change to hearing aids, or the purchase, fittings or adjustments of hearing aids; 35. The costs of cosmetic or reconstructive procedures, services or supplies except as specifically covered; 36. Charges for breast reduction or augmentation or complications arising from these procedures; 37. Outpatient Prescription or Legend Drugs, medications, vitamins, and mineral or food supplements, including pre-natal vitamins, or any over-the-counter medicines, whether or not ordered by a Doctor; 38. The cost of any drug or other item to treat hair loss; 39. Expenses incurred in the treatment of weak, strained, flat, unstable, or unbalanced feet, metatarsalgia, bunions, spurs, or the removal of corns, calluses or toenails, unless specifically for the treatment of a metabolic or peripheral vascular disease or for the prompt repair of an Injury sustained while coverage is in force for the Covered Person; 40. Expenses incurred in the treatment of acne or varicose veins; 41. The costs of weight loss programs, diets, or treatment of obesity; 42. Transportation charges, except as specifically covered; 43. Expenses for rest or recuperation cures or care in an extended care facility, convalescent nursing home, a facility providing rehabilitative treatment, Skilled Nursing Facility, or home for the aged, whether or not part of a Hospital, unless specifically covered; 44. Costs of services or supplies for personal comfort or convenience, including homemaker services or supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel, including but not limited to bathing, dressing, feedingsed routine skin care, bladder care and administration of oral medications or eye drops, except as specifically covered; 45. Costs of services or supplies furnished or provided by a member of your Immediate Family; 46. Expenses for diagnosis or treatment of a sleeping disorder; 47. Expenses incurred in the treatment of Injury or Sickness resulting from participation in skydiving, scuba diving, hang or ultra light gliding, riding an all terrain vehicle such as a dirt bike, snowmobile or go-cart, racing with a motorcycle, boat or any form of aircraft, any participation in sports for pay or profit, or participation in rodeo contests; 48. Expenses for the purchase of a noninvasive osteogenesis stimulator (bone stimulator); 49. The costs of services or supplies of a common household use, such as exercise cycles, air or water purifiers, air conditioners, allergenic mattresses, and blood pressure kits; 50. Expenses for surgery during the first 6-months after the Effective Date of coverage for a Covered Person for a total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis of carcinoma (subject to all other coverage provisions, including but not limited to, the Preexisting Conditions exclusion); tonsillectomy; adenoidectomy; repair of deviated nasal septum or any type of surgery involving the sinus; myringotomy; tympanotomy; herniorraphy; or cholecystectomies.