FAQ

Q: What limitations, exclusions and reductions are included in Ansel's certificate of insurance and riders?

A: While Ansel is designed to be simpler, our plans have some limits, exclusions, and reductions of coverage that apply in certain situations. A complete description of benefits, limitations, and exclusions are provided in the certificate of insurance and riders, but we’ve included a summary below.

Benefit Details

Your Ansel plan pays benefits if you are diagnosed with any of 13,000+ covered conditions during the plan year. You can file a claim any time you are diagnosed but there are a few limits you should know about.

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Separation Periods
First, our plans have separation periods, which means that after you file a claim, you can’t file another claim in the same category (Moderate, Severe, or Catastrophic) until the separation period has passed between the dates of your diagnoses. The separation period for Moderate claims is 14 days. For Severe claims, the separation period is 30 days, and for Catastrophic claims, the separation period is 90 days. The separation period only applies to claims in the same category, so if you are diagnosed with a covered Moderate condition and a covered Severe condition at the same time, you can file claims for both.

Other Claims Limitations
If you’re still in ongoing treatment after the 90 day Catastrophic separation period ends, you may be able to file another claim under certain circumstances. However, you can only file a maximum of 3 times for an ongoing condition within the same condition group in your lifetime. However, if you have multiple catastrophic conditions during the year (for example if you have a heart attack in January, cancer diagnosis in April, and Alzheimers diagnosis in August), you’ll be covered since they are in different condition groups and the 90 day separation period had passed between diagnoses.

Waiting Periods
You can enroll in Ansel anytime throughout the year but if you enroll, or add a family member, after the Open Enrollment period has ended, you are considered a “late entrant” and you will have a 60 day waiting period before any claims will be approved.

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Exclusions

We will not pay benefits for an Injury or Sickness that is contributed to, caused by, or resulting from:

1. commission of or attempt to commit a felony, or voluntary participation in a riot or insurrection;
2. incarceration or imprisonment following conviction for a crime;
3. any condition diagnosed outside the United States, Mexico, or Canada, unless the Insured receives confirmation of the diagnosis in the United States;
4. active duty service or training in the military (naval force, air force or National Guard/Reserves or equivalent) for service/training extending beyond 180 days of any state, country or international organization, unless specifically allowed by a provision of this Certificate;
5. involvement in any declared or undeclared war or act of war (not including acts of terrorism), while serving in the military or an auxiliary unit attached to the military, or working in an area of war whether voluntarily or as required by an employer;
6. a Chronic Condition, except as specifically provided by a rider;
7. a Mental Illness, except as specifically provided by a rider;
8. a Maternity Condition;
9. “Not Covered” conditions as designated in the Conditions List attached to your certificate. Ansel plans don't cover common conditions (e.g. headaches, common cold, strep throat, etc.) For questions about specific conditions and coverage, email support@joinansel.com.
   
   Note: exclusions may vary by state. A complete description of benefits, limitations, and exclusions will be provided in your certificate of Insurance and applicable Riders. All coverage is subject to the terms and conditions of the master group policy.

Reductions of coverage

Benefits may be reduced at ages beyond standard retirement age. At age 70, your benefits reduce by 50%.
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Renewability, Cancellation, & Termination

Our plans are group policies, and are annually renewable. Your continued coverage depends on whether your employer renews the group policy. If your employer does not renew the policy, coverage ends for all employees. You may be eligible to continue, or “port”, your coverage if you leave your employer or if your employer discontinues the group policy. If your employer renews the policy, you will have the option to continue your coverage. Premiums may change on the policy anniversary and your employer’s contribution to policy premiums may also change. You may choose to terminate coverage before the next policy anniversary by letting your employer know your choice in writing.

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Q: How can I appeal a claims decision?

A: You can request a review of a benefit determination by submitting your appeal to us in writing at the following address:

Ansel Services Appeals
2093 Philadelphia Pike #2496
Claymont, DE 19703

The request for review must be made within 180 days from the date you receive notice of our benefit determination. If you request a review of a claim denial, we will complete our review no later than 30 days after we receive your request for review.

You or your authorized representative, such as a family member or physician, may appeal the decision by submitting comments, documents, or other relevant information to the appeal address referenced above. You may request copies (free of charge) of information relevant to your claim by contacting us at the above address.