Plan Benefit Highlights (cont.) Anesthesia Benefit Services of an anesthesiologist for bone marrow transplants, skin Cancer or surgical prosthesis implantation are not covered. Outpatient Hospital or Ambulatory Surgical Center Benefit Surgical procedures for skin Cancer are not covered. Second and Third Surgical Opinion Benefit Payable once per diagnosis of Cancer for a second surgical opinion, and a third if the second disagrees with the first. Surgical opinions for reconstructive, skin Cancer, or prosthesis surgeries are not covered. Prosthesis Benefit Payable for a prosthetic device and, if surgery required, its surgical implantation. Prosthetic related supplies such as special bras or ostomy pouches and supplies are not covered. Hair Prosthesis Benefit is payable once per covered person per lifetime when a hair prosthesis is needed. Extended Care Facility Benefit Pays for physician authorized confinement that begins within 14 days after a Hospital confinement. Physical or Speech Therapy Benefit Therapy must be provided by a caregiver licensed in physical or speech therapy. Hospice Care Benefit Payable when a physician determines terminal illness with life expectancy of 6 months or less and approves hospice care at home or in a hospice facility. This benefit does not include well baby care, volunteer services, meals, housekeeping services, or family support after the death. Home Health Care Benefit Pays for physician authorized private nursing care that begins within 14 days of a hospital confinement. This benefit does not include nutrition counseling, medical social services, medical supplies, prosthesis or orthopedic appliances, rental or purchase of durable medical equipment, drugs or medicines, child care, meals or housekeeping services, or physical or speech therapy. The service must be provided by a nurse or home health nurse’s aid and can not be a family member. Waiver of Premium Benefit If the primary insured becomes disabled due to Cancer and remains so for more than 90 continuous days, we will pay all premiums for policy and rider(s) due after the 90th day so long as the primary insured remains disabled. “Disabled” means the primary insured’s inability because of Cancer: to work at any job for which (s)he is qualified by education, training or experience; not working at any job for pay or benefits; and under the care of a physician for the treatment of Cancer. The policy must be in force at the time disability begins and the primary insured must be under age 65. Experimental Treatment Benefit Benefits for experimental treatment prescribed by a physician for treatment of Cancer will be provided the same as non-experimental treatment. Coverage for treatments received outside of the United States or its territories is not provided. Donor Benefit Pays if a donor incurs expenses on behalf of a covered person for a covered surgery due to organ transplant or a bone marrow/ stem cell transplant. Blood donor expenses are not covered under this benefit. Policy Form Series C11 Plan Codes 013-746, 013-747, 013-748 SB-30641(IN)(AFES)-1019 American Fidelity Assurance Company 9000 Cameron Parkway, Oklahoma City, Oklahoma 73114 800-662-1113 • americanfidelity.com This product may contain limitations and exclusions. This product is inappropriate for people who are eligible for Medicaid coverage. Dread Disease Benefit Covered dread diseases are: addison’s disease; amyotrophic lateral sclerosis; cystic fibrosis; diphtheria; encephalitis; grand mal epilepsy; legionnaire’s disease; meningitis; multiple sclerosis; muscular dystrophy; myasthenia gravis; niemann-pick disease; osteomyelitis; poliomyelitis; reye’s syndrome; rheumatic fever; rocky mountain spotted fever; sickle cell anemia; systemic lupus erythematosus; tay-sach’s disease; tetanus; toxic epidermal; toxic shock syndrome; tuberculosis; tularemia; typhoid fever; whipple’s disease. Inpatient Special Nursing Services Benefit Pays when Hospital confined and receiving physician authorized special nursing care (other than that regularly furnished by a Hospital) of at least 8 consecutive hours during a 24 hour period. See your policy for more information regarding the benefits listed above. Eligibility The policy/rider(s) will be issued only to those persons who meet American Fidelity’s insurability requirements, which includes satisfactory responses to medical questions. You, your lawful spouse and each natural, adopted or step child who is under 26 years of age are eligible to apply for coverage. Limitations and Exclusions The policy does not cover any other disease, sickness or incapacity even though after contracting Cancer it may have been aggravated or affected by Cancer or the treatment of Cancer except for conditions specifically stated in the dread disease benefit. Pre-Existing Condition A Pre-Existing Condition is a Cancer or dread disease for which, within 12 months prior to the effective date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession. Pre–Existing Conditions specifically named or described as excluded in any part of the policy are never covered. No benefits are payable for any covered person for any loss incurred during the first year of the policy as a result of a Pre–Existing Condition. Termination of Insurance Policy/rider(s) will terminate and coverage will end on the earliest of: the end of the grace period if the premium remains unpaid; or the end of the policy/rider(s) month in which we receive a written request from you to terminate the policy/rider(s); or the date of your death, if this is an Individual Plan. If the plan is other than individual the remaining covered persons may have the right to continue or convert their coverage. Coverage will terminate when they no longer meet the eligibility requirements. For the spouse, policy/rider(s) will terminate and coverage will end on the earliest of: The end of the policy/rider(s) month in which we receive a written request from you to delete the spouse from the policy/rider(s); the end of the premium term in which a divorce, annulment, legal separation is obtained; or upon their death. For the child(ren), policy/rider(s) will terminate and coverage will end the earliest of: The end of the policy/rider(s) month in which we receive a written request from you to delete the child(ren) from the policy/rider(s); or upon their death. Guaranteed Renewable You are guaranteed the right to renew your policy/rider(s) during your lifetime as long as you pay premiums when due or within the premium grace period. We have the right to increase premiums by class. AF™ Limited Benefit Individual Cancer Insurance