CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Fixed Indemnity Enrollment and Administrative Form

Governs enrollment, beneficiary designation, coverage selection, and administrative changes for a fixed indemnity (non-health-insurance) group policy issued by Dearborn Life Insurance Company (Blue Cross and Blue Shield of Oklahoma trade name). Affects employers, employees, spouses, and dependents covered under group arrangements.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyFixed Indemnity Enrollment and Administrative Form

Policy CodePolicy N/A

Change TypeMinor / No material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit enrollment forms directly to the issuer unless the group is self-administered; if self-administered, submit only when evidence of insurability is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Fixed indemnityPolicy type clarification

Lombard, ILAdministrative office

Employer/Employee rulesEnrollment submission

IncludedCOBRA

MultipleBenefit options

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Enrollment, Benefit Selection, and Administrative Criteria

Benefit selection rules

Available basic and voluntary coverages may be selected on the enrollment/change form; employer may require a health questionnaire for certain elections.

ALL of the following

One or more of
- Term Life / AD&D
- Dependent Term Life / AD&D
- Accident
- Spouse coverage
- Child(ren) coverage
- Family coverage
- Short-Term Disability (STD)
- Long-Term Disability
- Critical Illness
- Hospital Indemnity

Form notes: availability, cost, and whether a health questionnaire is required are determined by the employer/plan administrator.

Enrollment submission

Instructions for submitting enrollment and change forms.

Submit enrollment forms directly to the issuer unless the group is self-administered.

If the group is self-administered, submit enrollment forms to the issuer only when evidence of insurability is required.

Beneficiary designation

Rules for naming beneficiaries for life and AD&D coverage.

Employee must complete beneficiary designation if applying for Life or AD&D insurance.

If two or more primary beneficiaries are named and benefit percentages are not listed, proceeds will be paid in equal shares to surviving primary beneficiaries.

If benefit percentages are listed for primary beneficiaries, the total must equal 100%.

If no primary beneficiary survives, proceeds will be paid to the contingent beneficiary(ies).

Employee is the beneficiary of proceeds from spouse or child coverage.

Policy change and cancellation

Administrative changes to coverage and cancellation options captured on the form.

Reasons for policy change (select as applicable)

Married
Birth / Adoption
Widowed
Divorced
Address Change

Cancellation/termination reasons (select as applicable)

Enrollment and cancellation criteria

Enrollment status, coverage tier selections, and cancellation/waiver options recorded on the form.

Previously covered with group as

Employee (termination, reduction in hours, other)
Spouse (divorce from Employee, death of Employee)
Dependent (reached age limit, married, no longer a Full Time Student, other)
Spouse & Dependents (divorce from Employee, death of Employee, other)

Termination / cancel coverage reasons

Terminate Coverage

Form Codes and Data Field Capture

Issuer identificationmixed

Insurance products issued by Dearborn Life Insurance Company; Blue Cross and Blue Shield of Oklahoma is the trade name of Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148.

Enrollment data fieldsmixed

No codes listed

Dependent age / FTS / Handicapped

Dependent age limitForm instructs to indicate when dependent children are over the age limit

Full Time Student (FTS)For adult children over the age limit, form provides a flag to indicate Full Time Student status and requests name of accredited school

Handicapped (HDCP)Form provides a flag to indicate if an adult child is Handicapped

Dependent identifiers collectedForm captures dependent Last Name, SSN, Date of Birth, Relationship, and Sex

Policy Type Notices and Required Actions

Note

Fixed indemnity policy — limited dollar payments; not health insurance

This is a fixed indemnity policy and not comprehensive health insurance; payments are limited dollar amounts, may be capped annually, and are not based on the size of medical bills. The policy is not a substitute for comprehensive health insurance and does not include most Federal consumer protections that apply to health insurance.

Payments may be limited each year.
Members remain responsible for the full cost of care; indemnity payments are set dollar amounts, not billed-charge reimbursements.

Documentation Required

COBRA continuation section — dates, signature, and waiver

The form includes a COBRA continuation privilege section that captures a start date and a projected end date and requires the employee's signature. The form also provides a written waiver option where the employee can decline enrollment and acknowledge future enrollment opportunities are subject to company arrangements.

Fields: Start Date and Projected End Date for COBRA continuation.

Key Definitions

Fixed indemnity policy

DefinitionFixed indemnity policy is NOT health insurance; may pay a limited dollar amount for sickness or hospitalization and is not a substitute for comprehensive health insurance

Payment basisPayments are not based on the size of medical bills and there may be annual limits on amounts paid

Consumer protectionsBecause it is not health insurance, it does not have to include most Federal consumer protections that apply to health insurance

Spouse (includes Domestic Partner / Civil Union)

Primary definitionSpouse includes Domestic Partner and Party to a Civil Union as defined in the Certificate

Usage on formPhrase 'Spouse includes Domestic Partner and Party to a Civil Union' appears on multiple coverage and enrollment sections (Term Life, AD&D, Enrollment tiers)