FSG - Fairmont Specialty Covered Expenses

Just because you don't have health insurance right now doesn't mean you won't have health problems. Select STM allows you and your family to purchase high quality, affordable medical coverage on a temporary basis. Coverage is provided for physician services, surgery, outpatient and inpatient care.

How are benefits covered?
Select STM pays benefits for each covered person in the following manner:
First, you meet your deductible.
Choose from four options: $250, $500, $1,000 or $2,500
Then Select STM pays 80% or 50%
of the next $5,000 of covered expenses
After this, Select STM pays 100%
of covered expenses up to your lifetime maximum of $2 million

What medical expenses are covered?
After satisfying the deductible amount you have selected, Select STM will pay the coinsurance you selected for covered expenses, up to a lifetime maximum of $2,000,000 per policy period. Precertification is required prior to inpatient hospitalizations or surgery.

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 semiprivate 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 plasma 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
*Benefits vary by state. Refer to your coverage document for specific terms and conditions. The benefit amount shown is the lifetime maximum per covered individual per policy period.

Do I need precertification?
Pre-admission certification prior to eligible inpatient hospitalization or surgery by the covered individual within 48 hours is required. This is not a guarantee of benefits. Failure to precertify will result in a benefit reduction of 50%. Call 1-800-367-9938 for precertification.

What is a usual, reasonable and customary charge?
A "usual, reasonable and customary charge" is the charge typically made by physicians or suppliers of medical services, medicines and supplies within a specific geographic area.

Coverage Termination
Coverage ends when: the premium is not paid when due; you enter full-time active duty in the Armed Forces; you become eligible for Medicare; the policy terminates; the elected coverage period expires; The Insurance Company determines fraud or misrepresentation has been made in filing a claim for benefits; or a dependent ceases to be eligible.

Satisfaction guarantee
If you are not completely satisfied with this plan, and you have not filed a claim, you may return the Certificate of Insurance within 30 days and receive a premium refund.

This website provides a brief description of the benefits, limitations, exclusions and other provisions of the Short Term Medical Policy, Form AH27286 (or state variation) underwritten by TIG Insurance Company/TIG Premier Insurance Company/ Ranger Insurance Company. Benefits, benefit amounts, limitations, exclusions, and availability may vary by state. For complete details, read your coverage document immediately upon receipt.
©2003 HPA, Inc. All rights reserved.
TIG B-27286 6-12 12/03

Exclusions & Limitations

What are the plan's limitations and exclusions?
These services are not covered by Select STM:

• Any services that are not medically necessary
• Eye exams, eyeglasses, hearing aids and related surgeries
• Dental or orthodontic services
• Treatment of feet conditions
• Conditions resulting from an act of war, suicide attempt or high-risk sports
• Maternity and newborn treatment prior to discharge, any infertility treatments or sterilization treatments
• Services performed by family members or for which a charge would otherwise not be incurred
• Services payable by Medicare or Worker's Compensation coverage
• Cosmetic surgery
• Services for mental, nervous, alcohol or drug treatment
• Routine physical exams and tests, preventive care and immunizations for children over age 16.
• Experimental or investigational services
• Obesity treatments
• Sleep disorders
• Over-the counter-medications and prescription drugs
• Certain surgeries during the first six months

This is not a complete list of the limitations and exclusions. Please see the certificate of insurance for a complete listing.

Is there a pre-existing condition limitation?
Pre-existing conditions are not covered. This includes any condition or complication that was treated or produced symptoms five years prior to your Select STM effective date.

The pre-existing condition limitation may vary by state.

This website provides a brief description of the benefits, limitations, exclusions and other provisions of the Short Term Medical Policy, Form AH27286 (or state variation) underwritten by TIG Insurance Company/TIG Premier Insurance Company/ Ranger Insurance Company. Benefits, benefit amounts, limitations, exclusions, and availability may vary by state. For complete details, read your coverage document immediately upon receipt.
©2003 HPA, Inc. All rights reserved.
TIG B-27286 6-12 12/03

Instant Online Approval

HPA offers the fastest way to apply for health insurance because the plans offered on our website can be submitted and signed electronically. Our online process enables consumers to go through the entire purchasing process electronically, replacing the health insurance industry's traditional paper-based application process. Processing time is reduced because your application is immediately subjected to the insurance carriers underwriting guidelines for instant approval. There's no need to manually print and mail the applications for these plans. At the conclusion of this application, you will be able to print out your insurance documents for your personal records. Your policy will not be considered in-force until payment is received.

Eligibility & Effective Dates

You and your spouse under age 65 (and not eligible for Medicare) and you and your spouse's unmarried dependent children under age 19 (or under age 25 if a full-time student) who have a social security number and can answer "No" to the seven health questions on the application. Children age 19 and over should apply separately. Child-only coverage is available for ages 2 through 18. Child(ren) alone can apply and are to use the 0-24 premium rate (male or female, based on their gender) for the youngest child; and the per child rate for each of the child siblings to be insured. The minimum age for a child only coverage is 2 years old. The application must be completed and signed by the parent or legal guardian.

The insurance can be effective as early as 12:01 a.m. the next day after the transmission date. However, the applicant can choose a later effective date not to exceed 60 days from transmission date. Coverage ends on termination date listed in your policy.

Discount Card Program

About the UCSA Discount Plus Card
The United Consumers Savings Association provides members with numerous quality benefits that include money saving discounts for: Retail cost of prescription drugs; Dental services; Eye and vision care; Chiropractic services; Vitamin & Nutritional supplements; 24 Hour Nurse Help Line; Accudiet.com, an on-line interactive exercise and diet program; National Health Survey, discounts for Health & Lifestyle Assessment.
(This optional program is not affiliated with TIG Insurance Company/TIG Premier Insurance Company/Ranger Insurance Company, nor is it part of the Select STM insurance plan.)