LifeShield Advantage 5000/0/5000/1000000 - VA Short Term Health Plan from LifeShield - Healthpocket

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LifeShield Advantage 5000/0/5000/1000000

$135.82/mo
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Zip Code23464
Applicant2/17/1984 Male
Coverage Start2/18/2019
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Benefits & Coverage

Insurance TypeShort Term Medical Insurance
Insurance ProviderLifeShield
Plan TypePPO
Deductible$5,000
Coinsurance0% after deductible
Coverage Max$1,000,000
Application Fee$0
Plan TypeShort Term Medical Insurance
Office Visit for Primary Doctor$40 Copayment per visit per Covered Person. Benefit not subject to Coinsurance or Plan Deductible.
Office Visit for Specialist$40 Copayment per visit per Covered Person. Benefit not subject to Coinsurance or Plan Deductible.
Coinsurance0% after deductible
Annual DeductibleIndividual: $5,000.00
Family: $15,000.00
Separate Prescription Drugs DeductibleN/A
Prescription DrugsGeneric: Not covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Brand Name: Not covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Non-formulary: Not covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Annual Out-of-Pocket LimitIndividual: $5,000.00
Family: $15,000.00
Does Out-of-Pocket Limit include deductible?Yes
Lifetime Maximum$1,000,000.00
Out-of-Network CoverageYes
Out of Country CoverageNo

Physicians

Primary Care Physician (PCP) RequiredNo
Specialist Referrals RequiredNo

Preventive Care Coverage

Periodic Health ExamYes
Periodic OB-GYN ExamNo
OB-GYN Exam ConditionsNot Covered
Well Baby CareNo

Prescription Drug Coverage

Generic Prescription DrugsNot covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Brand Prescription DrugsNot covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Non-Formulary Prescription Drugs CoverageNot covered except those administered by a Doctor in an Inpatient or Outpatient setting covered under this Policy as an Eligible Expense.
Separate Prescription Drugs DeductibleN/A

Hospital Services Coverage

Emergency Room$500 additional deductible per visit for use of emergency room in the event of Sickness or Injury. The Deductible is waived if the Covered Person is directly admitted as an Inpatient for further treatment after which the Plan Deductible and Coinsurance will apply.
Outpatient Lab/X-RayNot Covered
Outpatient Surgery$500 additional deductible per surgery for Out-Patient Surgery after which Plan Deductible and Coinsurance will apply. Maximum of 3 Deductibles per Covered Person. Surgeries in excess of the maximum number of outpatient surgery deductibles will be subject to the Plan Deductible and Coinsurance
HospitalizationAverage Standard Room Rate: Average Standard Room Rate.

Maternity Coverage

Pre & Postnatal Office VisitNot Covered
Labor & Delivery Hospital StayNot Covered

Additional Coverage

Chiropractic CoverageNot Covered
Mental Health CoverageInpatient: $100 per day, 31 day maximum per Covered Person per Coverage Period. Outpatient: $50 per visit, 10 visits per Covered Person per Coverage Period

This Section explains how benefits are paid under the Policy. The section entitled ELIGIBLE EXPENSES lists the types of medical care that We cover and to what extent. In order for Us to pay benefits, You or the Covered Person must meet the following conditions:

  1. You or a Covered Person must receive medical care while coverage under the Policy is in force for such person;
  2. Medical care must not be excluded under PART VII – EXCLUSIONS AND LIMITATIONS; and
  3. Medical care must consist of services or supplies that a Doctor has prescribed and that are Medically Necessary for the diagnosis or treatment of a covered Injury or Sickness.

Copayment Amounts Defined:

  • Wellness Benefit Copayment – A copayment must be paid when Charges are incurred for an annual Routine Physical Exam.
  • Doctor Office Visit Copayment – A Copayment must be paid for each office visit for Charges incurred by a Doctor, Specialty Doctor or a Doctor consultation. Any other services or tests performed as part of the office visit will be subject to the Plan Deductible and Coinsurance.

Coverage Period Maximum Benefit

This is the maximum amount We will pay under the Policy per Covered Person, per Coverage Period.

What medical expense are covered?

The Policy covers the Eligible Expenses listed below. We apply these Eligible Expenses separately for each Covered Person.

An expense is “incurred” on the date a provider or facility performs the service or furnishes the supplies.

The following are Eligible Expenses under the Policy:

  1. Charges for Inpatient Hospital services:
    1. Daily room and board and nursing services not to exceed the average standard room rate. If a Hospital has only private rooms, Eligible Expenses will be limited to 90% of the private room charge;
    2. Daily room and board and nursing services in an Intensive Care or Critical Care Unit;
    3. Use of operating, treatment or recovery room; and
    4. Miscellaneous tests, services and supplies.
  2. Charges for Outpatient Hospital services.
  3. Charges for care received in a Hospital emergency room or a free standing emergency room.
  4. Charges for Surgery at an Outpatient Surgical Facility, including services and supplies.
  5. Charges for Inpatient Doctor visits.
  6. Charges made by a Doctor for surgery and other professional services.
  7. Charges for a surgical assistance or a surgeon assistant up to 20% of the Usual and Customary allowance for the primary surgical procedure performed during the operative session.
  8. Charges for the administration of anesthetics up to 20% of the Usual and Customary allowance for the primary surgical procedure performed during the operative session.
  9. Charges for a Doctor’s office visit, consultation, or urgent care center visit. Charges for other covered services or tests performed as a part of the office visit will be subject to the Plan Deductible and Coinsurance.
  10. Wellness Benefit: Charges for one annual Routine Physical Exam performed by a Doctor as part of a regular check-up in excess of the Copayment shown in the Schedule of Benefits. This includes a health history, an exam of all systems including cardiovascular, respiratory, neurological, musculoskeletal, reproductive and behavioral studies appropriate for age, risk and sex. This does not include blood work, radiology and/or labs.
  11. Charges for routine child health care for periodic visits that include a history, a physical examination, a development assessment, anticipatory guidance and appropriate immunizations and laboratory tests consistent with the Recommendations of Preventative Pediatric Health Care of the American Academy of Pediatrics from the moment of birth to age 16. Immunizations are not subject to the Plan Deductible.
  12. Charges for dressings, sutures, casts or other supplies which are administered by or under the supervision of a Doctor, but excluding nebulizers, oxygen tanks, supplies for use or application at home and all devices or supplies for repeat use at home.
  13. Charges for diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, intelligence, behavioral and educational testing are not included).
  14. Charges for artificial eyes or larynx, breast prosthesis or basic functional artificial limbs, but not their replacement or repair.
  15. Charges for reconstructive surgery directly related to surgery which is covered under the Policy, including reconstructive breast surgery and prosthetic devices incident to a Mastectomy. Coverage will also include all stages of reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction on a non-diseased breast to establish symmetry with the diseased breast and prostheses and physical complications of mastectomy, including lymphedemas. As used in this benefit: “Mastectomy” means the surgical removal of all or part of a breast as a result of breast cancer. “Reconstructive breast surgery” means surgery performed as a result of a mastectomy to reestablish symmetry between the two breasts and includes augmentation mammoplasty, reductive mammoplasty and mastopexy.
  16. Charges for radiation therapy or treatment and chemotherapy.
  17. Charges for blood and blood products, administration of blood and blood processing.
  18. Charges for an Extended Care Facility room and board accommodations; if:
    1. The Covered Person is receiving skilled nursing care as an Inpatient in that facility on the certification of the attending Doctor that the confinement is Medically Necessary;
    2. The confinement commences immediately following a period of at least three (3) continuous days of Hospital confinement; and
    3. The confinement is for the same covered Injury or Sickness that was treated during the Covered Person's confinement in the Hospital.
  19. Charges for treatment of a Covered Person by a Home Health Care Agency under a Home Health Care Plan. Eligible Expenses for Home Health Care are:
    1. Part-time skilled nursing care;
    2. Home Health aide services/supplies when under a R.N.’s direct supervision;
    3. Physical, occupational and speech therapy;
    4. Medical supplies; and
    5. Respiratory therapy.
    However, benefits will not be paid for charges made by a Home Health Care Agency for:
    1. Full-time nursing care at home;
    2. Meals delivered to the home;
    3. Homemaker services;
    4. Any services of an individual who ordinarily resides in the Insured’s home or is a member of the Insured's immediate family; or
    5. Any transportation services.
    Benefits for Home Health Care are in lieu of any similar benefits provided under any other provision of the Certificate.
  1. Charges for Hospice care and services incurred for a terminally ill Covered Person with a life expectancy of 6 months or less. Eligible Expenses include charges incurred for care and services when provided by an agency licensed or certified to provide hospice services, including the following:
    1. Inpatient and Outpatient care.
    2. Part-time or intermittent home nursing care by, or under the direction of a nurse;
    3. Physical, respiratory or speech therapy performed by a licensed therapist;
    4. Nutrition counseling provided by or under the direction of a registered dietitian; and
    5. Counseling by a licensed social worker, pastoral counselor for the Covered Person or a member of the Immediate Family, the primary care giver and individuals with significant personal ties to a Covered Person who is terminally ill.
    Hospice services must be:
    1. Under active management through an agency licensed or certified to provide hospice services and which is responsible for coordinating all such services; and
    2. Provided only if the Doctor submits written certification to Us that the Covered Person is terminally ill with a life expectancy of 6 months or less. Review of Medically Necessity may be periodically required.
    This benefit does not include the services of volunteers or persons who do not regularly charge for their services.
  2. Charges for ambulance transport to the nearest Hospital qualified to treat Injuries or medical emergencies. In order for benefits to be payable, transportation due to Sickness must result in Inpatient Hospitalization.
  3. Charges for the rental of a standard, basic Hospital bed and wheelchair, up to the purchase prices, not including expenses for customization and only for the portion of the cost equivalent to the Coverage Period.
  4. Charges for Physical Therapy, Occupational Therapy and Speech Therapy from a licensed or registered provider to improve or restore lost function caused by a Sickness or Injury covered under this Policy when ordered by the attending Doctor.
  5. Charges for organ or tissue transplants including all expenses related to the transplant before the transplant is performed, for the procurement of the donor organ or tissue, the Hospital expenses of the donor, and for follow-up care, including any complications while this coverage is in force.
    Eligible Expenses do not include organ or tissue transplants which:
    1. Are animal-to-human transplants;
    2. Use artificial or mechanical organs;
    3. Are Experimental or Investigative; or
    4. Are not generally accepted by the medical community as an effective treatment for a covered Injury or Sickness.
    5. For a condition that is excluded under PART VII – EXCLUSIONS AND LIMITATIONS.
  6. Charges for temporomandibular joint disorder (TMJ) procedures involving any bone or joint of the jaw, face, or head, so long as the procedure is Medically Necessary to treat a condition which prevents normal functioning of the particular bone or joint involved and the condition is caused by congenital deformity, disease, or traumatic Injury. Authorized therapeutic procedures include splinting and the use of intraoral prosthetics applied to reposition the bones. However, this does not include coverage for orthodontic braces, crowns, dentures, treatment for periodontal disease, dental root form implants or root canals.
  7. Charges for treatment rendered in a Hospital or by a licensed treatment facility or other provider licensed to treat a serious biologically-based Mental Disorders.
  8. Charges for treatment rendered in a Hospital or by a licensed treatment facility or other provider licensed to treat Substance Abuse.

Pre-Certification Requirements

  1. All Inpatient Hospitalizations and procedures done at an Outpatient Surgery Facility must be pre-certified.
  2. To comply with the pre-certification requirements, the Covered Person must:
    1. Contact the professional review organization at the following telephone number 1-800-641-5566 as soon as possible before the expense is to be incurred; and
    2. Comply with the instructions of the professional review organization and submit any information or documents they require; and
    3. Notify all Doctors, Hospitals and other providers that this insurance contains pre-certification requirements and ask them to fully cooperate with the professional review organization.
  3. If the Covered Person complies with the pre-certification requirements, and the expenses are pre-certified, the Company will pay Eligible Expenses subject to all terms, conditions, provisions and exclusions described in this Certificate.
  4. If the Covered Person does not comply with the pre-certification requirements, or if the expenses are not pre-certified, Eligible Expenses will be reduced by 50%.
  5. Emergency pre-certification: In the event of an emergency Hospital admission, pre-certification must be made within 48 hours after the admission, or as soon as is reasonably possible.
  6. Pre-certification Does Not Guarantee Benefits – The fact that expenses are pre-certified does not guarantee either payment of benefits or the amount of benefits. Eligibility for and payment of benefits are subject to all the terms, conditions, provisions and exclusions herein.
  7. Concurrent Review – For Inpatient stays of any kind, the professional review organization will pre-certify a limited number of days of confinement. Additional days of Inpatient confinement may later be pre-certified if a Covered Person receives prior approval.

Loss caused by, contributed to or resulting from the following is excluded or otherwise limited as specified:

  1. Pre-existing conditions:
    1. Charges resulting directly or indirectly from a condition for which a Covered Person received medical treatment, diagnosis, care or advice within the sixty-month period immediately preceding such person’s Certificate Effective Date are excluded for the first 12 months of coverage hereunder.
    2. Pre-Existing conditions includes conditions that produced any symptoms which would have caused a reasonable prudent person to seek diagnosis, care or treatment within the sixty-month period immediately prior to the Covered Person’s Certificate Effective Date of coverage under the Policy.

    This exclusion does not apply to a newborn or newly adopted child who is added to coverage in accordance with the policy’s eligibility and effective date of insurance.

  2. Waiting Period:
    1. Covered Persons will only be entitled to receive benefits for Sicknesses that begin, by occurrence of symptoms and/or receipt of treatment, more than 5 days following the Covered Person’s Certificate Effective Date of coverage under the Policy.
    2. Covered Persons will only be entitled to receive benefits for Cancer that begins, by occurrence of symptoms or receipt of treatment more than 30 days following the Covered Person’s Certificate Effective Date of coverage under the Policy.
  3. Expenses during the first 6 months after the Certificate Effective Date of coverage for a Covered Person for the following:
    1. Total or partial hysterectomy, unless it is Medically Necessary due to a diagnosis of carcinoma;
    2. Tonsillectomy;
    3. Adenoidectomy;
    4. Repair of deviated nasal septum or any type of surgery involving the sinus;
    5. Myringotomy;
    6. Tympanotomy;
    7. Herniorraphy; or
    8. Cholecystectomy.
    However, if such condition is a Pre-Existing Condition any benefit consideration will be in accordance with the Pre-Existing Conditions limitation.
  4. The benefits payable for the following conditions or procedures are limited to the specified amounts shown in the Schedule of Benefits:
    1. Kidney Stones
    2. Appendectomy
    3. Joint or Tendon Surgery
    4. Knee Injury or Disorder
    5. Acquired Immune Deficiency Syndrome (AIDS)/ Human Immuno-deficiency Virus (HIV)
    6. Gallbladder Surgery
  5. Mental, emotional or nervous disorders or counseling of any type, except as specifically covered as an Eligible Expense.
  6. Treatment for Substance Abuse, unless specifically covered under the Policy as an Eligible Expense.
  7. Outpatient Prescription Drugs, unless specifically covered under the Policy as an Eligible Expense.
  8. Medications, vitamins, and mineral or food supplements including pre-natal vitamins, or any over-the-counter medicines, whether or not ordered by a Doctor.
  9. Any drug, treatment or procedure that either promotes or prevents conception including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal of sterilization.
  10. Any drug, treatment or procedure that corrects impotency or non-organic sexual dysfunction.
  11. Modifications of the physical body in order to improve the psychological, mental or emotional well-being of the Covered Person, such as sex-change surgery.
  12. Surgeries, treatments, services or supplies for cosmetic or aesthetic reasons, except for reconstructive surgery where expressly covered under the Policy.
  13. Weight modification or surgical treatment of obesity.
  14. Eye surgery, such as LASIX, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
  15. Dental treatment and dental surgery except as necessary to restore or replace sound and natural teeth lost or damaged as a result of a covered Injury.
  16. 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 or other conditions of the joint linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the joint, unless specifically covered under the Policy as an Eligible Expense.
  17. Routine pre-natal care, Pregnancy, child birth, and post natal care. (This exclusion does not apply to “Complications of Pregnancy” as defined.)
  18. 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.
  19. Sclerotherapy for veins of the extremities.
  20. Abortions, except in connection with covered Complications of Pregnancy or if the life of the expectant mother would be at risk.
  21. Joint replacement or other treatment of joints, spine, bones or connective tissue including tendons, ligaments and cartilage, unless related to a covered Injury.
  22. Surgeries, treatments, services or supplies which are deemed to be Experimental Treatment.
  23. Chronic fatigue or pain disorders.
  1. Kidney or end stage renal disease.
  2. Treatment or diagnosis of allergies, except for emergency treatment of allergic reactions.
  3. Treatment for cataracts.
  4. Treatment of sleep disorders.
  5. Treatment required as a result of complications or consequences of a non-covered treatment or condition.
  6. Treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
  7. Treatment for acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic conditions of skin, nevus.
  8. Treatment for or related to any Congenital Condition, except as it relates to a newborn child or newborn adopted child added as a Covered Person.
  9. Treatment, medication or hormones to stimulate growth, or treatment of learning disorders, disabilities, developmental delays or deficiencies, including therapy.
  10. Spinal manipulation or adjustment.
  11. Biofeedback, acupuncture, recreational, sleep or mist therapy, holistic care of any nature, massage and kinestherapy, excepted as provided for under Home Health Care.
  12. Hypnotherapy when used to treat conditions that are not recognized as Mental Disorders by the American Psychiatric Association, and biofeedback and non-medical self-care or self-help programs.
  13. Eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, orthoptics, visual eye training and any examination or fitting related to these devices, and all vision and hearing tests and examinations.
  14. Care, treatment or supplies for the feet, orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions and treatment of corns, calluses or toenails.
  15. Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Doctor.
  16. Exercise programs, whether or not prescribed or recommended by a Doctor.
  17. Telephone or Internet consultations and/or treatment or failure to keep a scheduled appointment.
  18. Charges for travel or accommodations, except as expressly provided for local ambulance.
  19. All charges incurred while confined primarily to receive Custodial or Convalescent Care.
  20. Services received or supplies purchased outside the United States, its territories or possessions, or Canada, unless specifically covered under the Policy as an Eligible Expense.
  21. Any services or supplies in connection with cigarette smoking cessation.
  22. Any services performed or supplies provided by a member of the Insured’s Immediate Family.
  23. Services received for any condition caused by a Covered Person’s commission of or attempt to commit an assault, battery, or felony or to which a contributing cause was the Covered Person being engaged in an illegal occupation.
  24. Services or supplies which are not included as Eligible Expenses as described herein.
  25. Participating in hazardous occupations or other activity including participating, instructing, demonstrating, guiding or accompanying others in the following: operation of a flight in an aircraft other than a regularly scheduled flight by an airline, professional or semi-professional sports, extreme sports, parachute jumping, hot-air ballooning, hang-gliding, base jumping, mountain climbing, bungee jumping, scuba diving, sail gliding, parasailing, parakiting, rock or mountain climbing, cave exploration, parkour, racing including stunt show or speed test of any motorized or non-motorized vehicle, rodeo activities, or similar hazardous activities. Also excluded is Injury received while practicing, exercising, undergoing conditional or physical preparation for such activity.
  26. Injuries or Sicknesses resulting from participation in interscholastic, intercollegiate or organized competitive sports. This does not include dependent children participating in local community sports activities.
  27. Injury resulting from being under the influence of or due wholly or partly to the effects of alcohol or drugs, other than drugs taken in accordance with treatment prescribed by a Doctor, but not for the treatment of Substance Abuse.
  28. Willfully self-inflicted Injury or Sickness.
  29. Expenses resulting from a declared or undeclared war, or from voluntary participation in a riot or insurrection. This Exception does not apply to an act of terrorism.
  30. Expenses 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 the Covered Person on a pro-rated basis.
  31. Costs for Routine Physical Exams or other services not needed for medical treatment, unless specifically covered under the Policy as an Eligible Expense.
  32. Amounts in excess of the Usual and Customary charges made for covered services or supplies.
  33. Expenses You or Your Covered Dependent are not required to pay, or which would not have been billed, if no insurance existed.
  34. Expenses to the extent that they are paid or payable under other valid or collectible group insurance or medical prepayment plan.
  35. Charges that are eligible for payment by Medicare or any other government program except Medicaid. Costs for care in government institutions unless You or Your Covered Dependent are obligated to pay for such care.
  36. Expenses for which benefits are paid or payable under workers’ compensation or similar laws.
  37. Medical expenses which are payable under any automobile insurance policy without regard to fault (does not apply in any state where prohibited).
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Fayton, Charles
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Francisco, Reynaldo
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Chung, Michael
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Espada, Francisco
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Beatty, Maxine
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Gordon, Erin
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Drabik, Ashley
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Wulfsberg, Brittany
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Mascolo, Michael
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Gorman, Donna
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Smith, Theresa
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Benson, Morgan
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Duncan, Jenna
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Hughes, Sherri
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Malinis, Edgardo
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Chase, April
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Castelluzzo, Marlayne
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Watson, Lisa
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Kline Edwards, Debra
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Hennessey, Jordan
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Charles Fayton, M.D.
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  • Phone Number
    (757) 420-6218
  • Office Locations
    6477 College Park Sq
    Virginia Beach, VA 23464
6477 College Park Sq Virginia Beach VA, 23464

How do my benefits work?

Benefits are payable under the Policy after a Covered Person incurs charges for Eligible Expenses in excess of any applicable Additional Deductible, and then the Plan Deductible or Copayment, unless otherwise specified. Benefits will be paid at the Coinsurance amount shown in the Schedule of Benefits. Once the Out of Pocket Maximum amount is reached, the Coinsurance amount for the remainder of the Coverage Period is 100%. All benefits payable are subject to the Coverage Period Maximum Benefit. Your Schedule of Benefits shows Your Plan Deductible, Additional Deductibles, Copayment, Coinsurance amount, Out of Pocket Maximum amount and Coverage Period Maximum Benefit. Reimbursement is also subject to any benefit limitations shown in the Schedule of Benefits.

What is a Plan Deductible?

The Plan Deductible is the amount of Eligible Expenses a Covered Person must incur during a Coverage Period before We pay benefits.

What is a Family Deductible Maximum?

Once 3 family members have met their respective Plan Deductible in a Coverage Period, no further Plan Deductible will be required for the remainder of the Coverage Period. The Family Deductible Maximum does not apply to any additional Deductibles.

Type of Deductibles included in this plan:

Outpatient Surgery Deductible – An additional deductible that must be satisfied for Charges incurred for surgery performed in an Outpatient Surgical Facility. There is a maximum of 3 Deductibles per Covered Person per Coverage Period. Surgeries in excess of the maximum number of outpatient surgery deductibles will be subject to the Plan Deductible and Coinsurance.

Emergency Room Deductible – An additional deductible must be paid for Charges incurred for use of an emergency room in the event of Sickness or Injury. The Deductible is waived if the Covered Person is directly admitted as an Inpatient for further treatment after which the Plan Deductible and Coinsurance will apply.

Advanced Diagnostic Studies Deductible – An additional deductible must be satisfied for each day Charges are incurred in a non-Hospital setting for Advanced Diagnostic Studies, including PET, MRI and CAT scans after which the Plan Deductible and Coinsurance will apply.

Does the plan require Pre-Certification?

All Inpatient hospitalizations and procedures done at an Outpatient Surgery Facility must be pre-certified. LifeShield National Insurance Co.'s professional review organization must be contacted as soon as possible before the expense is to be incurred. If the Covered Person does not comply with the Pre-certification requirements as stated in the insurance certificate, the Eligible Medical Expenses will be reduced by 50%.

How does Usual and Customary Fees affect my benefits?

The Policy defines Usual and Customary Fees as the usual, fair and reasonable fee for medical treatment provided to a Covered Person (or any other form of medical care, procedure, drug or supply).

In determining a Usual and Customary Fee, the Company at its discretion, consults:

  1. one (1) or more standard industry sources to calculate services of comparable severity and nature in the same geographical area, the cost of the goods and services reasonably required to produce and deliver such treatment and/or the charge most commonly paid for such treatment. The standard industry sources utilize cost-based formula methodology and/or pricing data (updated semi-annually) to produce replicable and consistent cost and/or pricing parameters;
  2. the cost to the health care provider of performing or providing the medical treatment, including reasonable allowance for overhead and profit;
  3. fee schedules used by third parties such as Medicare or Medicaid, including Medicare allowable charge data for Medicare Part B;
  4. hospital cost data as submitted to Medicare, including Medicare allowable charge data for Medicare Part A; and
  5. prevailing negotiated fee schedules for same or similar services performed in the same geographical area.

All benefits are limited to Usual and Customary Fees. Usual and Customary Fee definition may vary by state.

What if members change their minds after the purchase of LifeShield Advantage STM coverage?

If not 100% satisfied with coverage and members have not already used any of the insurance benefits, they may return the certification to us within 10 days of receipt. Coverage will be cancelled as of the effective date and the plan cost will be returned. No questions asked!

What is the Pre-Existing Conditions Limitation?

Charges resulting directly or indirectly from a condition for which a Covered Person received medical treatment, diagnosis, care or advice within the 60* month period immediately preceding such person's Certificate Effective Date. A Pre-Existing condition includes conditions that produced any symptoms which would have caused a reasonable prudent person to seek diagnosis, care or treatment within the 60* month period.

* varies by state

What is an Out-Of-Pocket Maximum?

It means an amount of allowable expenses that is the responsibility of each Covered Person to meet before the Company will begin paying the expenses at 100%. It does not include Deductibles, Copayments, penalty coinsurance for failure to pre-certify required services or charges in excess of the Usual and Customary Charge. Once the Out of Pocket Maximum is met, the Policy will begin paying 100% of allowable Usual and Customary costs for the remainder of the Coverage Period, not to exceed Coverage Period Maximum Benefit and any applicable benefit limits.

Who is eligible to apply for this insurance?

LifeShield Advantage STM is available to members and their spouses, who are between 18 and 64 years old and their dependent unmarried children under 26 years old; and can answer "No" to all of the questions in the application for insurance. Child-only coverage is available for ages 2-25.

When does the LifeShield Advantage STM coverage terminate?

Coverage under the Policy will cease at 12:01 a.m. for a Covered Person, based on the time zone in the place where the Insured resides, on the earliest of the following:

  1. The date premiums are not paid in accordance with the terms of the Policy, subject to the Grace Period;
  2. On the next premium due date after the Company receives a written request from the Insured to terminate coverage, or any later date stated in the request;
  3. The date an Insured performs an act or practice that constitutes fraud, or is found to have made an intentional misrepresentation of material fact, relating in any way to the Policy, including claims for benefits under the Policy;
  4. The date of the Insured's death or the termination date of the Insured's coverage, if the Insured's spouse is not covered under the Policy;
  5. The date the Insured obtains other insurance, excluding Medicare;
  6. The Certificate termination date stated on the Schedule of Benefits.
  7. The date that members enter full-time active duty in the armed forces of any country or international organization other than for reserve duty of 30 days or less;
  8. The date other major medical insurance coverage becomes effective for a Covered Person;
  9. The date that insurance under the Policy is discontinued; or
  10. The first day of any policy month We elect to terminate the Policy by giving the Group Policyholder at least 30 advance written notice.
PremiumPlan NameDeductible
from $55AdvantHealth Plan 1 5000/20/9000/500000$5,000.00Select
from $56AdvantHealth Plan 1 5000/20/7000/500000$5,000.00Select
from $108National General 5000/50/10000/250000 Extended$5,000.00Select
from $115AdvantHealth Plan 3 5000/20/9000/1000000$5,000.00Select
from $120AdvantHealth Plan 2 5000/20/9000/1000000$5,000.00Select

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.