For employee use only. For illustrative purposes only. May not be available in all jurisdictions. Coverage may be subject to limitations, exclusions and other coverage conditions contained in the issued policy. Please
consult the policy for the actual terms of coverage.
CONVERSION
The conversion privilege allows you to convert your LTD insurance
coverage to an individual policy if your coverage terminates.
ACCIDENTAL DISMEMBERMENT BENEFIT
If you suer paralysis or a loss of hand, foot, sight or thumb
and index nger on the same hand due to an accidental injury,
we will pay a monthly benet. The benet will be 60% of your
monthly earnings minus any deductible sources of income.
You do not have to be disabled in order to receive this benet.
Please refer to the benet book for a list of losses and number
of monthly benet payments.
EDUCATION BENEFIT
For any disabled employee who has received Voluntary LTD
benets for at least six months and has a dependent child under
age 23 attending a school of higher learning on a full-time basis,
an Education Benet is payable. The monthly benet is $300 and
is for each child who qualies.
REHABILITATION BENEFIT
If the disabled employee is participating in a formal rehabilitation
plan approved by us while receiving benets, we will pay an
additional monthly benet equal to the lesser of 5% of their
Gross LTD Monthly Benet or $1,000. The Rehabilitation Benet
is payable for a maximum of 12 months.
CATASTROPHIC DISABILITY BENEFIT
If you are not working and catastrophically disabled due to
illness or injury, this benet provides an additional monthly
benet while you are receiving monthly LTD benets or
accidental dismemberment benets. A catastrophic disability
is one that either prevents you from being able to perform at
least 2 of the activities of daily living without the assistance/
supervision of another person or renders you cognitively
impaired. This benet is 10% of your pre-disability monthly
earnings up to a maximum of $5,000.
CAREGIVER RESPITE
If you are receiving the catastrophic disability benet, we may pay
a caregiver respite benet for each day of an informal caregiver’s
respite intervals. The benet is payable for medically necessary
companion care you receive during the caregiver’s respite.
CAREGIVER TRAINING
As part of the catastrophic disability benet, we may also pay a
benet if your informal caregiver incurs expenses to be trained to
provide informal home care to you during your disability. This benet
will pay a maximum of $500.
EMERGENCY ALERT SYSTEM
While you are receiving catastrophic disability benets, we may
reimburse you the cost of renting or leasing an emergency alert
system that allows you to remain in your home alone. In order to
qualify for this benet, the system must be medically necessary
and your condition is such that you cannot be left alone unless you
have an alert system. The benet is limited to $25 per month.
EXCLUSIONS AND LIMITATIONS
The plan does not cover any loss or disability caused by,
resulting from, arising out of or substantially contributed to,
directly or indirectly, by any one or more of the following:
1. a pre-existing condition
2. commission of, participation in or an attempt to commit an
assault or felony, including participation in a riot
3. intentionally self-inicted injuries
4. attempted suicide, regardless of mental capacity
5.
participation in a war, declared or undeclared, or any act of war
During a period of LTD, the plan has limitations on:
• Mental disorders—disability beyond 24 months after the
elimination period if it is due to a mental disorder of any type.
Connement in a hospital or institution licensed to provide
care and treatment for mental illness will not be counted as
part of the 24-month limit.
• Substance Abuse—a substance abuse (drug or alcohol)
related disability unless you are participating in a substance
abuse treatment program approved by the State where the
treatment program is provided. The cost of the treatment
program must be borne by you or another group plan of UT
System (such as a group health plan or Employee Assistance
Program) if one is available and covers this type of treatment.
Except as specically stated above, in no event will LTD monthly
benets for a mental disorder or substance abuse be paid
beyond the earliest of the date:
1. 24 LTD monthly benet payments have been made; or
2. the maximum period payable is reached; or
3. you refuse to participate in an appropriate, available
treatment program, or you leave the treatment program
before completion; or
4. you are no longer following the requirements of your
treatment plan under the program; or
5. you complete the initial treatment plan, exclusive of any
aftercare or follow-up services.
The lifetime cumulative maximum period payable for all
disabilities due to a mental disorder and substance abuse is
24 months. Only 24 months of benets will be paid for any
combination of such disabilities, even if the disabilities are not
continuous and/or are not related.
Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS
®
, BLUE SHIELD
®
and the Cross
and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
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