JUVENILE HOSPITAL INDEMNITY POLICY
Policy Number
37028140
12
01
Daily Benefit for
1st Day 2nd Day Thereafter
Name of Insured
JOHN J DOE
11
15
$160
M
$15.12
$130
Plan
$100
5ID
$168.00
07
Alternate
Agency
046
MONTHLY
Month
Day
Year
Effective Date
Age
Sex
Premium and
Frequency
Chosen by You
Branch
Premium
Insuring Clanse.
We will pay you the daily hospital benefit shown in the schedule above during any period of hospital confinement
subject to the limitations of this policy. Your coverage begins at 12:01 a.m. on the effective date of this policy and
continues while this policy is in force. Your coverage will cease at 12:00 midnight on the date of termination.
Right to Examine Policy.
Within ten days after this policy is first received, it may be returned to us or to the agent through whom it was
purchased. If returned, the policy will be as though it had never been issued. Any premiums paid will be returned.
PLEASE READ YOUR POLICY CAREFULLY.
'-',"' Guaranteed Renewable to
Age'::!l; Premiums Subject to C h a n g e " ' "
Your policy is guaranteed renewable until the termination date. Until such date and subject to the terms and conditions
of this policy, we cannot caucel or refuse to renew your policy. The terminatiou date of the policy will be the policy
anniversary following your 21st birthday. You may renew this contract before such date by paying each renewal
premium as it falls due or during the grace period. Should we accept a premium for any period after this policy is to
terminate, coverage will continue to the end of the period for which the premium has been accepted. We reserve the
right to change premium rates. A change in the rates will apply to all policies of this form issued by us and in force in
the state where you live. If we change the rates, your premium will be determined by: your age on the effective date of
this policy; and the year of issue of this policy. If we change the rates, we will write you 31 days or more before the
change at the address shown in our records. Subject to the terms and conditions of this policy, we will not restrict or
limit your policy in any other way while it is in force.
Signed for Liberty National Life Insurance Company as of the effective date.
Juvenile Hospital Indemnity Policy
Guaranteed Renewable to Age 21
Subject to Change in Premium Rates - Initial Premiums as Shown Above
Nonparticipating Policy
SIC/SID-Ed. 8-85
JHIPI
TABLE OF CONTENTS
Insuring Clause . . . . .
Right to Examine Policy
Guaranteed Renewable
Definitions
Benefits
Page
1
1
1
2
2
DEFINITIONS
We, Our, Us - Liberty National Life Insurance Company
YOu, Your - The person named as the insured under this
policy.
Usual and Customary Charge - The average charge made
by a doctor or hospital for a given service within a prescribed or determined geographical area.
Hospital - A hospital: is licensed and operates pursuant to
law; operates primarily for the care and treatment of sick or
injured persons as inpatients for a charge; provides 24-hour
nursing service under the supervision of a registered nurse;
is supervised by a staff of licensed physicians; and has
medical, diagnostic and major surgical facilities or has access to such facilities.
The term "hospital" does not include: convalescent, rest
or nursing facilities; facilities for alcoholics and drug addicts; any hospital contracted for or run by any government
except for services rendered where a legal liability exists for
charges made to the individual.
Hospital Confinement - Hospital confinement means continuous confinement in a hospital for more than 12 hours
upon the advice and recommendation of a licensed practicing
physician as the result of: an accidental injury sustained
while this policy is in force; or sickness or disease contracted while this policy is in force.
Pre-existing Condition - A condition for which medical
advice was given or treatment recommended by or received
from a physician within two years before the effective date.
BENEFITS
Daily Hospital Benefit. Subject to the exceptions below,
we will pay you a Daily Hospital Benefit as shown in the
schedule on page one.
Payment of such daily hospital benefit will not be made
for more than 180 days of hospital confinement during any
consecutive l2-month period. Any portion of a day in excess
of 12 hours shall be considered as a day.
If less than 30 days separates any two periods of hospital
confinement, then for the purpose of calculating daily benefits, such second period of hospital confinement will be
considered to be a continuation of the prior period.
Periods of hospital confinement resulting from different
and unrelated causes will be considered to be separate
periods of hospital confinement.
EXCEPTIONS
No benefit will be payable for any hospital confinement:
caused by mental or emotional disorders; occurring within
six months from the effective date of this policy in conSIC/SID Ed. 8-85
Page
Exceptions . . . . . . .
General Provisions
Endorsements (If Any)
Application
.
. . . . . . . . ..
. . . . . . . . ..
.. 2
.. 2
(Attached to the Policy)
(Attached to the Policy)
nection with any disease, disorder or surgical procedure
involving the tonsils, adenoids, appendix, a hernia, hemorrhoids or the reproductive organs; resulting from normal
pregnancy or childbirth; resulting from war or the act of
war (declared or undeclared) whether or not you are in
military service; for which no charge is made in the absence
of insurance, or which are covered under any governmental
plan except those governmental plans which by law either
define or specify disability insurance as primary; or resulting from any injury or sickness for which benefits are
payable under any worker's compensation or occupational
disease law.
GENERAL PROVISIONS
Consideration. The application and the payment of the
required premiums are the consideration for the policy. The
receipt of the first premium is hereby acknowledged.
Premium Payments
When Payable, Premiums are payable in advance beginning on the effective date. The schedule on page one
shows the amounts and frequency of premium payments.
Where Payable. Premiums are to be paid to us either at
one of our offices or to one of our agents. If premiums are
paid on a monthly basis, a premium receipt card may be
furnished. Failure of an agent to call for a premium collection when due does not excuse the premium payment. In
such event, premiums must be paid at one of our offices.
Frequency and Mode of Payment. Premiums may be paid
annually, semiannually, quarterly, or monthly. The frequency of premium payments may be changed with our consent
by filing a written request on a form satisfactory to and
accepted by us. The change will then become effective on
the next premium due date. The payment of any premium
shall not continue this policy in force beyond the date when
the next premium becomes due.
You may have elected to make your premium payment
under a special payment mode such as Bank Budget, Government Allotment, Weekly Deduction, or Payroll Deduction, if such a mode was available. Payment under one of
these modes shall cease if: authorization for payment under
such mode is terminated or withdrawn; or if a check drawn
and presented for payment under the Bank Budget mode is
not honored.
If payments cease under a special payment mode, you
should select a new payment mode. Otherwise we will bill
you by premium notice using the payment frequency we
select. In either instance the premium shall change from that
shown on page one. The new premium shall be what we
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JHI2TA
C
would have charged had the policy been issued on the new
payment mode. It will be due as of the end of the period
through which premiums were paid on the special payment
mode.
Entire Contract; Changes. This policy with any attached
papers is the entire contract between you and the Company.
No change in this policy will be effective until approved by
an officer of the Company. This approval must be noted on
or attached to this policy. No agent may change this policy
or waive any of its provisions.
Time Limit On Certain Defenses. After two years from
the date of issue of this policy no misstatements, except
fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or
to deny a claim for loss incurred or disability (as defined in
the policy) commencing after the expiration of such twoyear period.
Pre-Existing Conditions. A pre-existing condition is not
covered until two years after the effective date.
Grace Period. This policy has a thirty-one day grace period.
This means that if a renewal premium is not paid on or
before the due date, it may be paid during the grace period.
During the grace period, the policy will stay in force.
Reinstatement. If the renewal premium is not paid before
the grace period ends, the policy will lapse. Later acceptance of the premium by us or by our agent without
requiring an application for reinstatement will reinstate the
polley. If an application is required, you will be given a
conditional receipt for the premium. If the application is
approved, the policy will be reinstated as of the approval
date. Lacking such approval, the policy will be reinstated on
the forty-fifth day after the date of the conditional receipt
unless we have previously written you of its disapproval.
The reinstated policy will cover only loss resulting from
accidental bodily injury which occurs after the date of
reinstatement and sickness or disease which occurs more
than ten days after the date of reinstatement. In all other
respects your rights and our rights will remain the same,
subject to any provision noted or attached to the reinstated
policy.
Notice of Claim. Written notice of claim must be given
within thirty days after the commencement or occurrence of
any loss covered by this policy or as soon as reasonably
possible. The notice can be given to us at our home office or
to one of our agents. Notice should include your name and
policy number.
Claim Forms. When we receive a notice of claim, we will
send you forms for filing proof of loss. If you do not
receive these forms within fifteen days, you will meet the
proof of loss requirements by giving us a written statement
of the nature and extent of the loss within the time limit
stated in "Proofs of Loss."
Proofs of Loss. Written proof of loss must be given to us
within ninety days after the date of each loss covered by this
policy. If it was not reasonably possible to give written
SIC/SID Ed. 8-85
proof in the time required, we will not reduce or deny the
claim for this reason if the proof is filed as soon as reasonably possible. However, the proof required must be given
no later than one year from the time specified unless you
were legally incapacitated.
Time of Payment of Claims. Benefits provided by this
policy will be paid as soon as we receive proper written
proof of loss.
Payment Of Claims. If you are 18 years of age or older,
all benefits will be paid to you unless you direct otherwise
in writing. If you are less than 18 years of age, such
benefits will be paid to the person having control of this
policy. Any benefit unpaid at your death may be paid at our
option. to your surviving spouse or your estate. If the
benefits are payable to your estate or if you cannot execute a
valid receipt, we can pay benefits up to $ 3,000 to someone
related to you by blood or marriage whom we consider to be
entitled to such benefits. We will be discharged to the extent
of any such payments made in good faith.
Policy Control. If you are 18 years of age or older, you
may exercise all of the privileges granted to you under this
policy. If you are under 18 years of age, the parent, legal
guardian, or other adult having custody and control over you
will have those rights under the policy until your 18th
birthday.
Physical Examination. We may examine you when reasonably necessary for our consideration of your pending
claim. This wIi(be done at our expense.
..
Legal Action. No legal action may be brought to recover
on this policy within sixty days after written proof of loss
has been given as required by this policy. No such action
may be brought after the expiration on the applicable statute
of limitations from the time written proof of loss is required
to be given.
Misstatement Of Age. If your age has been misstated the
benefits provided by this policy will be those the premium
would have purchased at the correct age. For the purpose of
this policy, your age will be the age last birthday on the
effective date of this policy. If your coverage at the correct
age would not have become effective or would have terminated, then our liability will be limited to a refund. Such
refund must be requested by you and will be equal to the
portion of the premiums paid for the period not covered by
this policy.
Conformity With State Statutes. Any provision of this
policy which, on its effective date, is in conflict with the
laws of the state in which you reside on that date, is
amended to conform to the minimum requirements of such
laws.
Conversion. If coverage under this juvenile policy expires
due to reaching the policy anniversary date after the twentyfirst birthday, you may have an individual adult hospital
indemnity policy issued to you without evidence of insurability. The converted policy will be issued to you at
your attained age on the form we use for conversion from
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JHI2TA
this policy. You must then be eligible for the individual
adult policy as determined by our issue rules with respect to
age aud occupation. We will uot be required to issue auy
individual adult policies which would result in over-insurance as determined by our rules at the time of conversion. Written application for the policy and payment of
the first premium must be made within thirty-one days after
termination of insurance under this policy. The converted
policy, if issued, will take effect on the date of termination
of coverage under this policy. Any special exclusion in this
policy will also apply under any converted policy.
Insurance with Other Insurers. If there is other valid
coverage, not with us, providing benefits for hospital confinement, written notice of which has not been given to us
SIC/SID Ed. 8-85
prior to the occurrence or commencement of hospital confinement, the only liability for such hospital confinement
under this policy will be: for a proportion of the benefits
provided here for such hospital confinement as the like
benefits of which we had notice (including the benefits
under this policy) bear to the total amount of all such
benefits for hospital confinement; and for the return of such
portion of premium paid on this policy which exceeds the
pro rata portion of all such benefits.
For the purpose of applying this provision when other
coverage is on a provision of service basis, the "like benefits" of such other coverage will be taken as the amount
which the services rendered would have cost in the absence
of such coverage.
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JHI2TA
NOTICE
FOR ASSISTANCE IN RESOLVING COMPLAINTS,
OR TO OBTAIN INFORMATION ABOUT YOUR COVERAGE,
PLEASE CALL OUR HOME OFFICE AT 800-318-4542.
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PRIVACY POLICY
Liberty National Life Insurance Company cares about protecting its policyholders' privacy. In the
process of providing the products and services you requested, we will collect, use and share
certain information you provided. This Privacy Policy explains what information we collect and
how we use that information. The policy also explains how we protect the security and
confidentiality of your information.
Collection of Information
We collect and retain information necessary for us to provide the products and services you
requested. In that process we may collect non-public information from you as a result of: your
completion of an insurance application or other forms; your transactions and experience with us;
or from a consumer reporting agency such as the Medical Information Bureau.
Confidentiality of Information
We''<!o not disclose any non-public information about you, either during or after 'YlYU'!' relationship
with us, to anyone, except as permitted by law, such as to your authorized representative, or in
order to provide the products and services you requested, or to comply with applicable laws or
regulations.
Internal Protection of Information
We restrict access to non-public personal information about you to those employees who need to
know that information to provide the products and services you requested. We maintain physical,
electronic and procedural safeguards to comply with federal regulations to guard this information.
Disclosure of Our Privacy Policy
We are sending you this Notice for informational purposes and may amend this Privacy Policy at
any time and will update it as required. We also post our current privacy notice at our website:
www.libnat.com.
M903B, Ed. 4/02
M903B