2014-141 - Laserfiche WebLink

Home Browse Search

Sun Life Assurance Company of Canada Sun��= Stop-Loss special risk questionnaire Life Financial Section 1 Who is a special risk? Your employee benefit A person is a special risk if he or she is: plan covers any or all • receiving total parenteral nutrition(intravenous feeding); of the following: • confined to a medical (acute, skilled, or rehabilitation)facility or receiving home nursing care for 4 or more hours per day; employees, dependents, • being, or has been, evaluated, considered,or listed for an organ,tissue, stem cell, or bone marrow transplant or has received such a transplant; retirees, and those • using a left ventricular assist device, ventricular assist device, or internal defibrillator; receiving coverage • experiencing a high-risk pregnancy as determined by your precertification or pregnancy management vendors; under COBRA. Some • ventilator dependent; of these people are or • an employee who is not actively at work due to disability, who has been absent from work for more than 10 consecutive days within the might be a special risk. past 12 months, or who is working reduced hours due to illness or injury; or You must disclose • being re-enrolled, or has been re-enrolled, in the employer's medical benefit plan following his or her prior exhaustion of benefits under these individuals. the plan. In addition,a person is a special risk if he or she has been diagnosed with or treated for any of the following conditions within the past 12 months: • major trauma(e.g.,accident with multiple injuries • mental health or substance abuse disorder • hemophilia;other blood-clotting or internal injuries);amputation;severe burns that has required inpatient confinement disorders; Fanconi's disease • intracranial or other head injury • heart disease;cardiomyopathy;congestive • amyotrophic lateral sclerosis(ALS)or • spinal cord injury heart failure;dysrhythmias multiple sclerosis • acquired immune deficiency syndrome(AIDS) • congenital heart defect . Gaucher's disease • cancer or malignant neoplasm • primary pulmonary hypertension • chronic or acute liver disease; hepatitis • leukemia or lymphoma • chronic obstructive pulmonary disease • pancreatitis • cystic fibrosis • thrombocytopenia • acute or chronic renal disease • complications of pregnancy;multiple births; • cerebrovascular disease or stroke • regional enteritis premature birth;or newborn complications • arthritis(rheumatoid or osteoarthritis) • morbid obesity Section 2 How do you identify who is a special risk? There are two ways To identify who is or may be a special risk,you or your authorized representative should: to disclose special risk A. Attach any relevant reports(listed below)and highlight individuals falling into a special risk category(see above): individuals. Please read . pending claims report with diagnosis • report listing any participant who has incurred or is expected to this section carefully. . subrogated claims reports incur medical expenses(including prescription drug expenses) • precertification reports with diagnosis performed within equal to or greater than 50%of the specific benefit deductible the last 3 months Be sure to highlight special risks. Having a special risk individual simply appear on an attached report does not constitute disclosure. You may highlight special risk individuals by circling the name or by using an asterisk or other mark. XGR/1254 Stop-Loss special risk questionnaire Page 1 of 2