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