GemStar Group Vision Plan Guidelines and Exclusions
Eligibility
Eligible Employee Means
An individual employed by a participating employer who works 20 hours or more per week, and who is considered an employee for Social Security purposes. Partners and Proprietors are also considered to be eligible employees.
Eligible Dependent Means
- An employee's spouse; and
- Each unmarried child, from birth to age 19, who is living with You in a regular parent-child relationship and for whom You can claim an exemption on Your federal income tax.
- Each unmarried child, at least 19 years of age to 23 years of age (or as required by law) who is primarily dependent upon You for support and who is a full-time student. A full-time student is one who is enrolled for at least 12 semester hours for credit in an accredited junior college, college or university.
- Each unmarried child at least 19 years of age: (a) who is primarily dependent upon You for support because he is incapable of self-sustaining employment by reason of mental retardation or physical handicap; (b) who was incapacitated and insured under the Policy on his 19th birthday; and (c) who continues to be incapacitated beyond his 19th birthday.
Ineligible Firms
All require Home Office approval, please provide all available experience information:
• Assisted Living facilities
• Associations
• Athletes
• Businesses in existence less than 12 months
• Businesses operated from home
• Businesses with more than 20% turnover
• Car Dealerships
• Churches
• Consulting firms
• Continuing Care facilities/firms
• Dental Offices or other dental related businesses
• Fraternal Organizations
• Entertainers
• Grocery/Convenience stores
• Groups not paying Social Security
• Hotel/Motel/Lodging/Resorts
• Lodges
• Maids/Chauffeurs/Gardeners
• Management firms
• Medical practices
• MEWAs
• Multiple Employer Welfare associations
• Musicians
• Nursing Homes, etc.
• PEOs
• Real Estate Sales
• Religious Organizations
• Residential Care
• Restaurants <20 full-time EEs
• Retail Stores <20 full-time EEs
• Seasonal Businesses
• Taft Hartley Trusts
• Theaters
• Unions
This list of ineligible firms is representative only and not all-inclusive. The insurance company reserves the right to reject any firm.
General Information
Premiums, Renewability
Applicable Vision Premium Rates are guaranteed for each Employer Group for
24 months from date of issue. Thereafter, rates are subject to change in accordance with the Master Policy. Coverage is renewable as long as eligibility criteria are satisfied and premiums are paid when due.
Termination of Coverage
Coverage terminates on the earliest of the following dates: (a) the last day of the month in which You cease to be eligible for coverage; (b) the last day of the month in which Your Dependent is no longer a dependent as defined; (c) subject to the Grace Period, the last day of the month for which a premium has been paid by you or on your behalf; (d) or the date the Master Policy ends.
Coordination of Benefits
This Plan will be coordinated with any other group, blanket or franchise plan under which an individual will receive benefits. This helps keep the cost of the Plan reasonable.
Benefit Provisions, Limitations and Exclusions
Eligible Expenses
We will pay for Eligible Expenses You incur for Yourself or on behalf of Your insured Dependent. Expenses must be incurred while the Policy is in force and the person is covered by the Policy. The description of Eligible Expenses is shown in the Coverage Schedule. To be an Eligible Vision Expense, the vision service or procedure must be
performed by an optometrist, an ophthalmologist, or an optician.
Expenses Incurred
An Eligible Vision Expense is considered incurred on the date the vision
service is performed.
Vision Expenses Not Covered:
- Orthoptic or vision training and any associated supplemental testing.
- Plano lenses.
- Lens coatings.
- Two pair of glasses, in lieu of bifocals or trifocals.
- Medical or surgical treatment of the eyes.
- Any eye examination, or any corrective eyewear, required by an employer as a condition of employment.
- Any injury or illness when covered under any Workers' Compensation or similar law, or which is work-related.
- No-line bifocal or progressive lenses.
- Photo-chromatic lenses.
- Sub-normal vision aids or non-prescription lenses.
- Charges in excess of the Usual and Customary charge for the Service or Materials.
- Charges incurred after:
- the Policy ends; or
- the Insured's coverage under the Policy ends, except as stated in the Policy.
- Experimental or non-conventional treatment or device.
- Spectacle lens treatments or "add-ons," except solid tints (#1 & #2), and oversize lenses.
- High Index lenses of any material type.
VISION PLAN DESCRIPTIONS (click to view the plan description)
GemStar Vision Plan l Description
GemStar Vision Plan ll Description
GemStar Vision Plan lll Description
GemStar Vision Plan Comparison Chart (compares all three side by side)
GemStar Vision Plan Guidelines and Exclusions
Vision Terminology
Vision Frequently Asked Questions