American Health Shield Temporary Health Insurance Plan Highlights - Fairmont Specialty Group (FSG)
to a 08/2005 U.S. Department of Commerce report*, 45.8 million
Americans are without health insurance coverage. Don't risk being a
statistic - without health insurance coverage, an unexpected illness
or injury could be financially devastating!
U.S. Census Bureau / U.S. Department of Commerce / Economics and
Health Shield - Short Term Medical is a
quality, affordable plan of temporary medical insurance designed
specifically for healthy people who are temporarily without health
insurance. This plan offers
coverage from 30-days to 180-days or up to 12-months in most states that
can become effective as early as tomorrow and be paid for in one single
payment or easy monthly installments.
Ideal protection for persons:
Health Shield - Short Term Medical is not an HMO or PPO plan. In the
event of an illness or injury, and you may receive treatment from any
licensed healthcare provider or facility anywhere in the U.S.
Who is eligible to apply for the American Health Shield - Short Term Medical:
To be considered for coverage, persons listed on the application form must:
only coverage is available for your eligible, unmarried dependent child
(age 2 through 18) that live with you. Enter the oldest child as the
applicant, and all other child(ren) as dependents. Child(ren) only
applications must be signed by a parent or legal guardian, then mail
or fax all pages of the completed application to:
Term Medical Department
The American Health Shield - Short Term Medical provides benefits for Covered Medical Expenses related to covered Injury or Sickness, which are: 1) not in excess of Usual and Customary Charges; 2) not in excess of a maximum benefit amount; 3) made for services and supplies which are a Medical Necessity and listed as Covered Medical Expenses in the Policy or Certificate issued by Fairmont Specialty Group.
and Customary Charges
means the lesser of: 1) the actual charge; 2) what the provider would
accept for the same service or supply in the absence of insurance; or 3)
the reasonable charge as determined by Fairmont Specialty Group, based on
factors such as: a) the most common charge for the same or comparable
service or supply in a community similar to where the service or supply is
furnished; b) the amount of resources expended to deliver the treatment
rendered; c) charging protocols and billing practices generally accepted
by the medical community or specialty groups; or d) inflation trends by
plan requires a Pre-Admission Certification by a Professional
Review Organization prior to in-patient Hospitalization or surgery.
A Covered Person or
their Attending Physician must call the Professional
Review Organization: 1. For elective or non-emergency
Hospitalization or surgery, at least 10-days prior to the date of proposed
Hospitalization; 2. Within 48-hours of an emergency admission; or 3.
Within 48-hours of delivery for complicated childbirth.
Non-compliance with the Pre-Admission Certification procedure will
result in a reduction in benefits of 50%, unless the Covered
Person is incapacitated and unable to contact the Professional
Review Organization. In such cases, the Covered
Person must contact us as soon as possible.
Medical Expenses and Benefits vary by state.
Detailed information about these and additional Covered Medical Expenses
is listed in the Policy or Certificate issued by Fairmont Specialty Group
to approved applicants.
Health Shield - Short Term Medical let's you choose the payment
option (single or monthly payment) and payment method (automatic bank
draft, credit card, or personal check) that's most convenient for you.
Additionally, once coverage commences, premium rates are guaranteed for
the length of the Coverage Period issued! Note - If you
prefer to make payment(s) by personal check or money order, you must mail
your completed application form and initial payment to Fairmont Specialty
you submit the application form and initial payment via:
or facsimile, the earliest date that coverage can begin (if
approved by Fairmont Specially Group) is 12:01 a.m. on the day after
Fairmont Specially Group receives the completed application form and valid
electronic payment information. A later effective date may be
requested, but no more than 30 days following the application date. Note
- payment must be made by automatic bank draft or MasterCard / VISA.
Mail, the earliest date that coverage can begin (if approved by
Fairmont Specially Group) is 12:01 a.m. on the day after the postmark date
stamped by the U.S.P.S. on the envelope in which Fairmont Specially Group
receives the completed application form and payment for the total amount
due. If the U.S.P.S. postmark date is not legible or present, the
earliest date that coverage can begin is the day after the completed
application form and payment for the correct plan cost are received by
Fairmont Specially Group. A later effective date may be requested,
but no more than 30 days following the application date.
- The coverage Effective Date is determined by Fairmont Specially Group
and will be shown in the Policy or Certificate that is issued. No
agent or agency has the authority to bind, modify or issue coverage.
Issuance of coverage is subject to Fairmont Specially Groupís acceptance
of the submitted application form and your initial payment for the
American Health Shield - Short Term Medical.
will terminate on the earliest of the following dates:
last day of the period through which the premium is paid; The date the
Covered Person ceases to be eligible; or the Coverage Period expiration
a Covered Person is receiving benefits for a Hospital Confinement
on the date the Coverage Period, Policy or Certificate terminates,
benefits will continue in accordance with the terms of the Policy or
Certificate for as long as that Confinement
remains continuous and the Covered Person is Totally Disabled
by reason of such Injury or
Sickness. However, in no event will coverage continue beyond the
end of the 90-days following the date Coverage Period, Policy or
- Benefit payments for such condition both before and after the
Termination Date are subject to all applicable benefit maximum limits.
Once the "Extension of Benefits After Termination" provision has
been exhausted, all benefits cease to exist, and under no circumstances
will further payments be made.
American Health Shield - Short Term Medical is not
renewable nor intended to be permanent coverage. Coverage will
terminate upon expiration of your Coverage Period. However, you may
be eligible to apply for another Coverage Period following the expiration
of your previous Benefit Period. If a new Coverage Period is
applied for and issued by Fairmont Specially Group, there is no
continuous coverage between any previous and current Benefit Period.
Any condition or symptom, which occurred under a previous Coverage Period,
may be treated as a pre-existing condition under a subsequent Coverage
Period. Note - In no event will Fairmont Specially Group issue
successive Coverage Periods totaling more than 365 days.
Fairmont Specially Groupís receipt and approval of your submitted
application form, a Policy or Certificate will be issued and mailed to
your residence/home address. Please read the Policy or Certificate
carefully. It is important to us that you understand and are
satisfied with the American Health Shield - Short Term Medical
insurance plan. If you are not satisfied that this coverage will
meet your insurance needs, simply return the Policy or Certificate with
your written and signed request for cancellation within 10 days
after you receive it. Coverage will be canceled as of the effective
date and you will receive a full refund of your initial payment - no