GapPlusPlan.com for UBA Members

409 W VICKERY BLVD, FORT WORTH, TX 76104 | 866.438.4274

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Get Insured for Hospitalization

Gap HCI Plan

Member Driven Value.

Plan Costs

$100 per month - Individuals
$200 per month - Family 

Hospital Bed - In-Hospital Cash Indmenity with Gap HCI

Summary of Plan

Why Gap HCI Plan

Don't Deplete Your Savings

Don't rely on depleting your savings for health care expenses due to a hospital stay. Gap HCI Plan pays a lump sum daily benefit for each day an individual is confined in a hospital and more.

Did You Know
In 2015, there were a little over 35 million total admissions to Registered Hospitals in the United States.1


A total of 17.2 million hospital visits^ in the United States included at least one surgery in 2014. These visits included nearly 22 million total surgeries.2


In 2011, 26.9 percent of hospital stays in 29 States involved intensive care unit (ICU) charges, accounting for 47.5 percent of aggregate total hospital charges.3

Stats taken from:
1American Hospital Association (AHA) Hospital Statistics is published annually by Health Forum, an affiliate of the American Heart Association. Fast Facts on US Hospitals 2017. http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. ^(Ambulatory Surgery (AS) or Inpatient hospital Stays) 2HEALTHCARE COST AND UTILIZATION PROJECT Agency for Healthcare Research and Quality SATISTICAL BRIEF #223 May 2017 Surgeries in Hospital-Based Ambulatory Surgery and Hospital Inpatient Settings, 2014 Claudia A. Steiner, M.D., M.P.H., Zeynal Karaca, Ph.D., Brian J Moore, Ph.D., Melina C. Imshaug, M.P.H., and Gary Pickens, Ph.D. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb223-Ambulatory-Inpatient-Surgeries-2014.pdf. 3Barrett ML (M.L. Barrett, Inc.), Smith MW (Truven Health Analytics), Elixhauser A (AHRQ), Honigman LS (George Washington University, Washington DC Veterans Affairs Medical Center), Pines JM (George Washington University). Utilization of Intensive Care Services, 2011. HCUP Statistical Brief #185. December 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb185-Hospital-Intensive-Care-Units-2011.pdf
Group Accident & Sickness Limited Benefit Cash Insurance

PLAN DETAILS OF COVERAGE

BENEFITS

 Covered Member  100% of Benefit Amount
 Eligible Spouse of Covered Member  100% of Benefit Amount
 Eligible Dependent Child(ren) of Covered Member    50% of Benefit Amount
 65 Years Old on Date of Loss     50% of Benefit Amount
 70 Years Old on Date of Loss     25% of Benefit Amount


Group Policy No: 9908-17-48 issued to the United Business Association. Coverage becomes effective on the dates provided in your membership material. (Chubb Accident & Health, 202 Halls Mill Road, Whitehouse Station, NJ 08889.)

This Policy provides limited benefits on a fixed indemnity basis. It does not constitute comprehensive health insurance coverage (often referred to as "major medical coverage") and does not satisfy a person's individual obligation to secure the requirement of minimum essential coverage under the Affordable Care Act (ACA). For more information about the ACA, please refer to http://www.healthcare.gov.

This information is a brief description of the important features of this insurance plan. It is not an insurance contract. Coverage may not be available in all states or certain terms may be different where required by state law. Chubb NA is the U.S.-based operating division of the Chubb Group of Companies, headed by Chubb, Ltd. (NYSE:CB). Insurance products and services are provided by Chubb Insurance underwriting companies and not by the parent company itself. Federal Insurance Company and Chubb do not provide nor is affiliated with the discount programs provided as part of membership in the Untied Business Association.

The following monthly insurance rates apply to coverage underwritten by Federal Insurance Company. Your overall total association membership dues include these insurance rates.
Plan 1: Individual=$54.08; Ind+Spouse=$95.18; Family=$115.40
Plan 2: Individual=$57.55; Ind+Spouse=$101.29; Family=$122.82

Hospital Admission Indemnity Benefit

GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

 Benefit Amount per Hospital Admission  $750
 Max # of Admissions per Sickness
or Accident Per Plan Year
 1


We will pay a Hospital Admission Benefit if a Covered Person is admitted to a Hospital and Confined due to a Sickness or as the result of an Accident. The Covered Person must become confined within 6 months after the covered Accident. We will not pay more than the Maximum Benefit Amount, shown above.

No benefits will be paid for: Emergency Room Treatment; Outpatient Treatment; or a Stay of Less than 20 Hours in an Observation Unit.

In-Hospital Indemnity Benefit

GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

 Daily Benefit Amount  $1,000
 Max # Days per Period of Confinement  30 Days
 Max Benefit Amount Per Sickness &
 Accident Combined Per Plan Year
 $30,000


We will pay the daily In-Hospital Benefit Amount shown for each day a Covered Person is In-Hospital due to a Sickness or Accident. The first day of a Hospital stay must occur within thirty (30) days of the Accident, causing the injury.

A confinement for a Sickness shall not be combined with another Confinement for an Accident in determining a Period of Confinement. We will not pay more than the Maximum Benefit Amount, shown above.

 The In-Hospital Benefit Amount will be paid until the earliest of the date the:

  • Covered Person Dies;

  • Covered Person is No Longer In-Hospital; or

  • Maximum Number of Days Shown Above has Elapsed; or

  • Maximum Benefit Amount has been paid.




  • SPECIAL CONDITIONS WHICH APPLY TO THIS BENEFIT:
    If a Covered Person is discharged from the Hospital & a different Sickness or Accident causes such Covered Person to be In-Hospital again after 1 day of non-confinement, then We will consider it a new Period of Confinement. If a Covered Person is discharged from the Hospital and readmitted for the same Sickness or Accident as the prior Period of Confinement within 180 days of the prior Period of Confinement's discharge, it will be considered the same Period of Confinement.
    Surgical Indemnity Benefit - In Hospital

    GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

     Major Surgical Procedure Benefit Amount  $7,500
     Minor Surgical Procedure Benefit Amount  $500
     Max # of In-Hospital Procedures whether
     Major or Minor Surgical Procedures
     1

    *All Benefit Amounts are Per Covered Person Per Plan Year

    We will pay the Surgical Indemnity benefit amount if a Covered Person has a Major or Minor Surgical Procedure performed while In-Hospital. The benefit amounts are shown above.

    If two or more procedures are performed through the same incision or operative field, payment will be made only for the procedure of the larger benefit. If more than one procedure is performed but each through separate incisions or in a separate operative field, the amount payable shall be the specified amount for the primary procedure plus 50% of the amount payable for all other surgical procedures performed. A surgical procedure due to an Accident must occur within thirty (30) days of the Accident, causing the injury. We will not pay more than the Maximum number of Major or Minor Surgical Procedures in a Plan Year as shown above.

    Major Surgical Procedure: means a surgical procedure required to treat an injury caused by an Accident or Sickness that requires general anesthesia with respiratory assistance

    Minor Surgical Procedure: means a surgical procedure required to treat an injury caused by an Accident or a Sickness that is not considered a Major Surgical Procedure.

    Surgical Indemnity Benefit - Outpatient

    GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

     Major Surgical Procedure Benefit Amount  $3,750
     Minor Surgical Procedure Benefit Amount  $500
     Max # of Outpatient Procedures whether
     Major or Minor Surgical Procedures
     1

    *All Benefit Amounts are Per Covered Person Per Plan Year

    We will pay the Surgical Indemnity Amount if a Covered Person has a Major or Minor Surgical Procedure performed while in an Outpatient Unit. An Outpatient Unit means a licensed treatment center that has permanent facilities, a Physician present during all operating hours; and ancillary services, including laboratory and X-ray, staffed during all operating hours. The benefit amounts are shown above.

    If two or more procedures are performed through the same incision or operative field, payment will be made only for the procedure of the larger benefit. If more than one procedure is performed but each through separate incisions or in a separate operative field, the amount payable shall be the specified amount for the primary procedure plus 50% of the amount payable for all other surgical procedures performed. A surgical procedure due to an Accident must occur within thirty (30) days of the Accident, causing the injury. We will not pay more than the Maximum number of Major or Minor Surgical Procedures in a Plan Year as shown above.

    Major Surgical Procedure: means a surgical procedure required to treat an injury caused by an Accident or Sickness that requires general anesthesia with respiratory assistance

    Minor Surgical Procedure: means a surgical procedure required to treat an injury caused by an Accident or a Sickness that is not considered a Major Surgical Procedure.

    Intensive Care Unit Indemnity Benefit

    GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

     Daily Benefit Amount  $100
     Max # Days Per Period of Confinement  30 Days
     Maximum Benefit Amount Per Sickness &
     Accident Combined Per Plan Year
     $3,000

    We will pay the daily Intensive Care Unit Benefit Amount shown above, for each day of Confinement if an Accident or Sickness causes a Covered Person to be Confined in an Intensive Care Unit. This benefit is paid in addition to the In-Hospital Benefit Amount. The first day of Confinement in the Intensive Care Unit must occur withing thirty (30) days of the Accident. We will not pay more than the Maximum Benefit Amount shown above.

     The Intensive Care Unit Benefit will be paid until the earliest date:

  • Covered Person Dies;

  • Covered Person is No longer Confined in an Intensive Care Unit; or

  • Maximum Number of Days Shown Above has Elapsed




  • SPECIAL CONDITIONS WHICH APPLY TO THIS BENEFIT:
    A Confinement for a Sickness in an Intensive Care Unit shall not be combined with another Confinement in an Intensive Care Unit for an Accident in determining a Period of Confinement. If a Covered Person is discharged from the Hospital and a different Sickness or Accident causes such Covered Person to be Confined in an Intensive Care Unit In-Hospital again after 1 day of non-confinement, then We will consider it a new Period of Confinement. If a Covered Person is discharged from the Hospital and readmitted to an Intensive Care Unit for the same Sickness or Accident as the prior Period of Confinement within 180 days of the prior Period of Confinement's discharge, it will be considered the same Period of Confinement.
    Physician Office Visit Indemnity Benefit

    GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

     Per Visit Benefit Amount  $35
     Max # of Visits Per Sickness or
     Accident Per Plan Year
     2


    We will pay the Physician Office Visit Indemnity Benefit Amount, as shown above for a Physician Office Visit as a result of an Accident or Sickness. The visit must be made to the Physician's office or clinic. The visit to a Physician's office must occur within (30) days of the Accident, causing an injury. We will not pay more than the Maximum Benefit Amount, shown above.

    Benefits are not payable for
    • Visits made by a Physician while the Covered Person is Confined in a Hospital;
    • Routine Eye Examinations, or Fitting of Glasses or Fitting of Hearing Aids;
    • Dental Examinations or Dental Care other than expenses resulting from Accidental Injury; or
    • Annual Physicals, School Sports Physicals, and other types of Preventive Visits not required due to an Accident or Sickness.
    Emergency Room Indemnity Benefit

    GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

     Per Visit Benefit Amount  $300
     Max # of ER Visits Per Sickness &
     Accident Per Plan Year
     2


    We will pay the Emergency Room Benefit Amount, shown above, if an Accident or Sickness causes the Covered Person to require and receive Emergency Medical Care in an Emergency Room of a Hospital. Treatment must be received within 24 hours of the Accident. We will not pay more than the Maximum Benefit Amount, shown above.

    State Availability

    GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

    Gap HCI Plan State Availability

    Plan 1:
    AL, AZ, AR, DE, DC, FL, GA, IL, IN, IA, KY, MI, MS, NC, NE, ND, NM, OH, OK, PA, RI, SC, TN, TX, VA, WI & WY

    Plan 2: CA & NV

    View Gap HCI Sample Member Guide

    GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

    Click on Link below to View Gap HCI Plan Sample Member Guide

    Click here to view Gap HCI Plan Sample Member Guide

    Group Insurance Certificates

    GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

    Find Your State Listed Under Either Plan 1 or Plan 2.
    Then select the appropriate certificate to view / download

    Plan 1 - Gap HCI Group Insurance Certificates

    Available in these states:
    AL, AZ, AR, DE, DC, FL, GA, IL, IN, IA, KY, MI, MS, NC, NE, ND, NM, OH, OK, PA, RI, SC, TN, TX, VA, WI, and WY.

    Individual Only Plan 1 Group Insurance Certificate for Gap HCI Individual + Spouse Plan 1 Group Insurance Certificate for Gap HCI Family Plan 1 Group Insurance Certificate for Gap HCI



    Plan 2 -Gap HCI Group Insurance Certificates

    Available in these states:
    CA & NV.


    Individual Only Plan 2 Group Insurance Certificate for Gap HCI Individual + Spouse Plan 2 Group Insurance Certificate for Gap HCI Family Plan 2 Group Insurance Certificate for Gap HCI
    Claim Information

    For Claims Assistance:

    United Business Association Claims Unit
    HSR, 4100 Medical Parkway, Carrollton, TX 75007
    Phone: 1.866.523.3452
    Fax: 1.972.512.5824
    Email: ubaclaims@hsri.com
    Reference the Policy Number: 9908-17-48


    Click here to download Gap HCI Claim Form

    Benefit Payment is subject to the terms, conditions, limitations, exclusions and other provisions within the Policy and/or Rider. For more information and complete details of terms, conditions, limitations, and exclusions of coverage, please refer to the Policy and/or Rider. Coverage may vary and may not be available in all states. A copy of the Certificate is available from the Association upon request. Written Claims Notice must be given to Us within twenty (20 days after the occurrence or commencement of any loss covered by this policy or as soon as reasonably possible. Notice must include enough information to identify the Covered Person and the Policyholder. Failure to give Claim Notice within twenty (20) days will not invalidate or reduce any otherwise valid claim if notice is given as soon as reasonably possible.

    Exclusions & Limitations

    For Group Accident & Sickness Limited Benefit Cash Insurance

    This insurance does not apply to:

    1. Any Accident caused by or resulting from, directly or indirectly, a Covered Person’s participation in scuba diving to depths of more than 130 feet; skydiving; hang-gliding or para-gliding; parascending other than over water; bungee jumping; mountaineering or rock climbing normally requiring the use of guides or ropes; or caving.

    2. Any Accident or Sickness caused by or resulting from, directly or indirectly, the Covered Person’s commission or attempted commission of a felony or being engaged in an illegal occupation. (Does not apply for Plan 2 - CA & NV residents).

    3. Any Accident or Sickness caused by or resulting from, directly or indirectly any occurrence while the Covered Person is incarcerated.

    4. Alcoholism or drug or substance abuse. In addition, the insurance does not apply to any confinement in a detoxification facility or drug or alcohol rehabilitation facility that is not also a Hospital or part of a Hospital.

    5. Any Accident or Sickness caused by or resulting from, directly or indirectly, the Covered Person being under the influence of any narcotic or other controlled substance at the time of the loss. This exclusion does not apply if any narcotic or other controlled substance is taken and used as prescribed by a Physician. (Does not apply for Plan 2 - CA & NV Residents.)

    6. Sickness caused by or resulting from a Covered Person’s Pre-Existing Condition if the Sickness occurs during the first 12 months that a Covered Person is insured under this policy. Pre-Existing Condition means an Accident or Sickness for which, in the 6 months before the Covered Person becomes insured under the policy, medical advice, treatment or care was sought by a Covered Person, or was recommended by, prescribed by or received from a Physician.

    7. Normal pregnancy. Complications of Pregnancy are covered as any other Sickness.

    8. Pregnancy of a Dependent Child, unless required by law.

    9. Any Accident caused by or resulting from, directly or indirectly, the Covered Person participating in any professional sporting activity for which the Covered Person received a salary or prize money.

    10. Any rest care or custodial care or treatment for any Accident or Sickness.

    11. Any Accident caused by or resulting from, directly or indirectly, the Covered Person being engaged in or participating in a motorized vehicular race or speed contest.

    12. Any Accident or Sickness caused by or resulting from, directly or indirectly, the Covered Person participating in military action while in military service with the armed forces of any country or established international authority.

    13. No benefits are payable related to the Covered Person’s suicide, attempted suicide or intentionally self-inflicted injury.

    14. Voluntary abortion, except with respect to You or Your covered Spouse or Domestic Partner where such person’s life would be endangered if the fetus were carried to term.

    15. Any Accident or Sickness caused by or resulting from, directly or indirectly, war, undeclared war, civil war, insurrection, rebellion, revolution, warlike acts by a military force or personnel, any action taken in hindering or defending against any of these or any consequences of any of these acts regardless of any other direct or indirect cause or event, whether covered or not, contributing in any sequence to the loss.

    16. Routine newborn or well baby care, including routine nursery charges.

    17. Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit or which are payable under Occupational Disease Law, Workers Compensation or similar law, whether or not application for such benefits have been made.

    This policy does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit the provision of insurance, including but not limited to the payment of claims.

    Terms & Disclaimers

    GROUP ACCIDENT & SICKNESS LIMITED BENEFIT CASH INSURANCE

    Disclosures

    If insurance is included in any Gap Plan, it is not basic health insurance or major medical coverage and does not qualify as minimum essential coverage under the Affordable Care Act. You must be a member of the United Business Association (UBA) to access and enroll in any Gap Plan that provides an insured benefit. Various insurance companies, as described, have issued group limited benefit insurance policies to the United Business Association as the group master policyholder. You must purchase UBA Membership in order to purchase this additional plan.



    UBA Refund / Cancellation Policy

    If you are not completely satisfied with your UBA Gap Plan, please call your Personal Member Concierge at 866.438.4274. We will be happy to issue a complete refund of membership dues within the first thirty (30) days. We want you to be 100% satisfied with your UBA Gap benefits and services.

    Note: This membership is separate from any other insurance or supplemental plan you have purchased. Please contact your agent for any plans other than the UBA Gap Membership Plan. If you are canceling, please make sure to cancel using our cancellation phone number at 866.438.4274 or our cancellation form located at gapplusplan.com/billing.html. Please do not cancel through your agent. Cancel directly with GAP to make sure your cancellation request is handled promptly and correctly.

    30 Day Money Back Guarantee
    Hospital Admission Indemnity
    In-Hopsital Indemnity Beenfit
    Surgical Indemnity Benefit
    Intensive Care Unit Indemninty Beenefit
    Physician Office Visit Indemnity Benefit
    Emergency Room Indemnity Benefit
    Gap HCI Plan