Description / Exclusions / Application

InterM^sm is designed for people who have a temporary need for medical coverage and who are healthy. InterM^sm gives you peace of mind by providing coverage for injuries and sudden-onset illnesses

InterM^sm is designed to provide medical coverage on a temporary basis to fill a temporary need. It cannot be renewed and is not intended to replace permanent coverage. However, if the temporary need continues, you may apply for one new policy within a 12-month period.

HOW THE POLICY WORKS

• You choose the term of coverage - a minimum of 30 days up to the maximum policy term of 185 days.
• You select the deductible amount - $250, $500, $1,000 or $2,500 per covered person.
• After the deductible is met, the policy pays the rate of payment you have selected - either 80% or 50% of the next $5,000 - and then 100% of the balance of covered expenses up to a maximum benefit of $1,000,000 during the policy term.

No family will be required to satisfy more than a total of three times the individual deductible. Covered expenses for all eligible family members may be accrued to satisfy the family deductible.

COVERED EXPENSES
Covered expenses are charges for services or supplies prescribed by a physician for treatment of an illness or injury covered by your policy. The charges must be incurred for medically necessary care while the policy is in effect. A covered expense is incurred on the date a service is rendered or received and may not exceed usual and customary or reasonable as defined in your policy.

Subject to the limitations and conditions described in the policy, the following services and supplies will be considered covered expenses under your policy:

• Hospital room, board, and general nursing care, limited to the hospital’s average semiprivate room charge, unless confined in a coronary or intensive care unit.
• Other hospital services including emergency room, outpatient and ambulatory surgical center charges.
• Skilled nursing facility room, board, and general nursing care, limited to the facility’s average semi-private room charge, up to a maximum of 100 days (other limitations apply; see your policy for complete description of benefit).
• Physician services for diagnosis, treatment, and surgery.
• X-rays, radioactive treatment, and laboratory tests.
• Breast and pelvic exams, mammograms, and Pap smear exams (if such exams are related to an annual women’s examination).
• Anesthesia and oxygen and their administration.
• Private nursing care by R.N. or L.P.N. in the home (limitations apply).
• Licensed ambulance service, limited to two trips per illness or injury (other limitations apply; see your policy for complete description of benefit).
• Physical, occupational, speech and audiological therapy, up to 30 sessions (other limitations apply).
• Home health care (up to 40 visits) when prescribed by a physician and rendered by a licensed home health agency (see your policy for complete description of benefit).
• Rental (up to purchase price) of wheel chair, hospital type bed, or other durable medical equipment unique to medical care or treatment.
• Initial placement of a prosthesis required for functional purposes.
• Blood and blood products, administration of blood, and blood processing.
• Drugs which require the written prescription of a physician (limitations apply).
• Non-prescription elemental enteral formula for home use if the formula is medically necessary for the treatment of severe intestinal malabsorption (see your policy for complete description of benefit).
• Organ transplants, including heart, kidney, liver and bone marrow transplants, up to a maximum of $250,000 (other limitations apply; see your policy for complete description of benefit).
• Kidney disease.
• AIDS, including AIDS, AIDS Related Complex (ARC) or related immuno deficiency disorders.
• Casts, splints, crutches, orthopedic braces, colostomy bags, catheters, syringes, dressings, and initial contact lens following cataract surgery performed while covered under the policy.

EXTENSION OF BENEFITS WHILE HOSPITALIZED
If a covered person is hospital confined on the date your policy ends, coverage for that person only will continue without payment of additional premium. The coverage will continue until the person is discharged from the hospital or until the benefit maximum is reached, whichever occurs first.

This is not the insurance contract and only the actual policy provisions will govern. Please refer to the policy for a detailed description of the rights and obligations of both you and Regence Life and Health Insurance Company.