Supplemental Medical Plan
Form 7002 9/02 NC ONLY

Supplemental Group Hospital/Medical Indemnity Plan

NCFlex is offering a supplemental hospital and medical indemnity plan called Supplemental Medical. The plan is underwritten by Kanawha Insurance Company in Lancaster, South Carolina. Supplemental Medical is designed to supplement your medical plan by providing benefits for physician's office visits and providing an inpatient hospital lump sum benefit. Benefits are paid directly to you. Please understand this plan provides limited benefits and is not a replacement for comprehensive medical coverage.

 

Your Supplemental Medical Benefits

 

Benefit Payment

Maximum

Overall Calendar Year Maximum

Sickness*

Physician's Office Visit

 $50 per visit $150 per sickness $450 per each Covered Person up to $900 per family

Emergency Room

 $100 per visit

Annual Physical Exam**

Benefit available after 6 months of coverage

$100 per Covered Person

$200 per calendar year for all Covered Persons

 $450 per each Covered Person up to $900 per family

Outpatient Accidental Injury***

Physician's Office Visit

$100 per visit

$400 per injury

$900 per each Covered Person up to $1,800 per family

Emergency Room

$200 per visit

Inpatient Hospital*

Benefit Payment

$250 per Covered Person per calendar year

N/A

N/A

*Pregnancy covered as any other sickness.
**At least two of the following procedures must be performed: 1) cardiovascular stress test, 2) blood chemistry determination, 3) EKG, 4) mammogram, 5) prostate specific antigen test, 6) digital prostate examination, 7) pap smear, or 8) urinalysis.
***Treatment must begin within 72 hours of the accidental injury.

 

Downloads

Kanawha's Supplemental Medical Plan Brochure (5308)

NCFlex Supplemental Medical Plan Claim Form (6270)

Your Monthly Premiums

Age at Issue

Employee Only

Employee & Spouse

Employee & Child(ren)

Family

Employee 18 - 50
Spouse 18 - 50

$16.08

$32.16

$35.38

$51.46

Employee 18 - 50
Spouse 51 - 69

$16.08

$41.42

$35.38

$60.72

Employee 51 - 69
Spouse 51 - 69

$25.34

$50.68

$44.64

$69.98

Employee 51 - 69
Spouse 18 - 50

$25.34

$41.42

$44.64

$60.72

 
   
This plan contains Limitations and Exclusions. Underwritten by Kanawha Insurance Company.