Association Membership Includes:
TWO WAYS TO SAVE
SAVE 20-30% THROUGH THE MULTIPLAN NETWORK,
IN ADDITION TO THE INSURED BENEFITS ABOVE!
This program includes the MultiPlan Limited Benefit Plan Network.
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Select Network: Choose Multiplan and then Limited Benefit Plan.
Question: Who is eligible for "Guaranteed Issue?"
Answer: Any Primary Member between the ages of 18 - 64, who is gainfully employed outside the home and working an average of 27+ hours per week at the time of application. Anyone who does not have a pre-existing history of Cystic Fibrosis. Once issued, there is no requirement to maintain a fulltime working statue in order to renew the policy through age 65. Spouses age 18-64 may be covered, regardless of their working status, as well as children to age 19, or 23 if full time students (9+ credit hours)
Question: How are Pre-Existing Conditions treated?
Question: Are there any Pre-Existing Medical Conditions that would make an otherwise qualified applicant ineligible for the EMA Victory Program?
Answer: YES!, there is one illness which is an automatic decline and that is Cystic Fibrosis. Certain specific Pre-existing medical conditions will receive a permanent exclusion for coverage under the policy. At the time of printing ( 10/18) they are COPD and End Stage Renal Disease.
AL, AR, AZ, CA, DE, FL, GA, IA, IL, IN, KY, LA, MD, MI, MO, MS, NC, NE, NV, OH, OK, PA, SC, TN, TX, UT, VA, WI, WV
THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. [LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.]
AUTHORIZATION: Authorization to Obtain and Release Information: I hereby authorized any licensed physician, medical practictioner,hospital, clinic laboratory, pharmacy, pharmacy benefit manager or other medical facility, insurance or reinsurance company, MIB, Inc. ("MIB"), Division of Motor Vehicles (DMV), the Veterans Administration or other medical or medically related facility that has any health, or DMV records of me to give to the Manhattan Life Assurance Company, of America ("the Company") or its insurers, any such information. All information used or disclosed (excluding disclosures of information relating to human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDs), and AIDs related complex (ARC)) pursuant to authorization may be subject to redisclosure by the recipient and may no longer be protected.
I authorize ManhattanLife Assurance Company of America, or its reinsurers, to make a brief report of my protected health information to MIB.
I understand that I am authorizing the Company to receive my health information, prescription drug usage history and my non-medical information. I understand that prescription drug usage may be used to verify the presence of certain medical conditions and that such history will not be used to decline coverage. These medical conditions will be confirmed by a telephone interview prior to being used in the underwriting process. The released information received by the Company will remain protected by federal and/or state regulations. I understand that the information requested is necessary for the evaluation and the underwriting of my application for the policy for which I have applied; to determine eligibility for insurance, risk rating or policy issue determinations; to obtain reinsurance; to administer claims and determine or fulfill responsibility for coverage and provision of benefits; and, to conduct other legally permissible activities that relate to any coverage I have, or have applied for, with the Company.
I understand that telephone interviews may be a part of the application process and that any information obtained from such telephone interviews may be used to decline my application for coverage. I understand that failure to provide the authorization to the Company will result in the rejection of the Insurance Policy coverage.
I understand that I may revoke this authorization at any time by notifying the Company in writing at their Administrative Office: 10777 Northwest Freeway, Houston, Texas 77092. I understand that such revocation will not have any effect on actions the Company took prior to their receiving the revocation notice.
I understand that this authorization will be valid for twenty-four (24) months from the date signed if used in connection with an application for an insurance policy, reinstatement of an insurance policy, change in policy benefits, or for the duration of a claim if used for the purpose of collecting information with a claim for benefits under a policy. A photographic copy of this authorization shall be as valid as the original. I understand that I am, or a person authorized to act on my behalf it, entitled to receive a copy of this authorization.
I agree and understand that no insurance coverage will be in force until the effective date specified by the Company. No Agent or Broker is authorized to make or modify any policy or waive any of ManhattanLife Assurance Company of America rights or requirements or waive the answer to any question in the application. No change to the policy will be valid until approved by an Officer of the Company which must be noted on or attached to the policy. The policy with this application and any endorsements, riders or other papers, if any, is the entire contract of insurance. I hereby apply for insurance coverage to be issued solely and entirely in reliance upon the written answers to the foregoing questions and/or information obtained by the Company in its underwriting process. I and my agent certify that I have read or had read to me all the questions and answers in this completed application and such answers to the best of my (our) knowledge and belief are true and complete. I understand and agree that the falsity of any answer or statement in this application which materially affects the acceptance of the risk or hazard assumed by the Company may bar the right to any recovery under any policy(s) issued contracts waive any Company rights or requirements or waive any information the Company requests.
Notice of Information Practices Including Fair Credit Reporting Act Notice and MIB, Inc. Notice To obtain further information, contact Manhattan Life Assurance Company of America 10777 Northwest Freeway, Houston, TX 77092
Thank you for your application. It is the major source of information about you which we use in evaluating your application and reviewing your policy. However, we wish to inform you that an investigative consumer report may be ordered as to your insurability. If an investigative consumer report is prepared in connection with this application, you may request to be interviewed in connection with the preparation of this report. This report may include, if applicable, information as to your character, general reputation, personal characteristics and mode of living as may be obtained through interviews with family members, friends, neighbors and associates. If you would like to know whether such a report was ordered and, if so, receive additional information as to its nature and scope, including the name, address and phone number of the reporting agency, we will be pleased to furnish this information upon your written request to our Administrative Office at the above address. You may receive a copy of such report by contacting the reporting agency.
Our experience shows that information from investigative reports usually does not have any adverse effect on our underwriting decision. However, if it should, we will notify you in writing of this fact as well as provide you the identity by name and address of the reporting agency. You may then wish to discuss the matter with that agency. We will not disclose information about you without your prior written authorization except as permitted by law. In certain situations we may disclose, as allowed by law, all types of nonpublic personal information as is necessary in order to conduct our business.
This could include disclosures to persons or organizations that will use the information for sales purposes, unless you indicate to us that you do not want the information disclosed for this purpose. You have the right to obtain access to certain items of information we have collected about you, and you have the further right to request correction of information if you feel it is inaccurate. If you wish to have a more detailed description of our information practices, we will be pleased to furnish this information upon your written request to our Administrative Office at the address on the front of this Notice.
MIB, Inc. Pre-Notice Information regarding your insurability will be treated as confidential. ManhattanLife Assurance Company of America or its reinsurers may, however, make a brief report thereon to the MIB, Inc., formerly known as Medical Information Bureau, a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information about you in its file.
Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at 866-692-6901 (TTY 866-346- 3642). If you question the accuracy of the information in MIB's file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB's information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734.
ManhattanLife Assurance Company of America, or its reinsurers, may also release information from its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at www.mib.com.
By entering your Mother's maiden name you are electronically signing the application thereby giving us authorization to obtain information and process the application. Clicking "Submit" acknowledges that you have read and agree to the Consent and Disclosure to Use Online E-Signatures. [ Click to print/download ]
|Standard||1-5 business days||$7.95|
|Two Day||2 business days||$15|
|Next Day||1 business day||$30|
|* Free on orders of $50 or more|