Section E: Terms, conditions, and authorizations
Eligible Dependent means:
• Your spouse, domestic partner, or child age 26 or younger, including a newborn, natural child, a child for whom you have assumed a parent-
child relationship, or a child placed with you for adoption, a stepchild or any other child for whom you have legal guardianship or court
ordered custody. Coverage for children will end on the last day of the month in which the children reach age 26 unless he or she qualifies as a
disabled person.
• A child (at any age during initial or continued enrollment), who is incapable of self-sustaining employment by reason of physically or mentally
disabling injury, illness, or condition; and is chiefly dependent upon the Subscriber for support and maintenance.
• Dependents eligible for continued coverage under California State or Federal laws.
In signing this, I represent that:
• I am requesting coverage for myself and all Dependents as listed above and authorize my Employer to deduct any required contributions for
this insurance from my earnings.
• I understand all benefits are subject to conditions stated in the Group Policy.
• I have read or have had read to me the completed application, and I realize fraud or intentional misrepresentation of material fact in the
application may result in loss of coverage.
Binding Arbitration
All disputes including but not limited to disputes relating to the delivery of services under the agreement or any other issues related to the
agreement and claims of medical malpractice must be resolved by binding arbitration (with the sole exception of Adverse Benefit Determinations,
as defined in Section 147.136 of Title 45 of the Code of Federal Regulation), if the amount in dispute exceeds the jurisdictional limit of small claims
court and the dispute can be submitted to binding arbitration under applicable federal and state law, including but not limited to, the patient
protection and affordable care act. It is understood that any dispute including disputes relating to the delivery of services under the agreement or
any other issues related to the agreement, including any dispute as to medical malpractice, that is as to whether any medical services rendered
under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered will be determined by submission
to arbitration as permitted and provided by federal and California law, and not by a lawsuit or resort to court process except as California law
provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to
have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
You and Cigna agree to be bound by this arbitration provision and acknowledge that the right to a jury trial or to participate in a class action is
waived for both disputes relating to the delivery of service under the agreement or any other issues related to the agreement and medical
malpractice claims.
The Federal Arbitration Act shall govern the interpretation and enforcement of all proceedings under this BINDING ARBITRATION section. To the
extent that the Federal Arbitration Act is inapplicable, or is held not to require arbitration of a particular claim, State law governing agreements to
arbitrate shall apply. The arbitration findings will be final and binding except to the extent that State or federal law provides for the judicial review
of arbitration proceedings.
The arbitration is initiated by the Member making a written demand on Us. The arbitration will be conducted by a single neutral arbitrator from
Judicial Arbitration and Mediation Services (“JAMS”), according to JAMS’ applicable Rules and Procedures. If for any reason JAMS is unavailable
to conduct the arbitration, the arbitration will be conducted by a single neutral arbitrator from another neutral arbitration entity, by agreement of
the Member and Oscar, or by order of the court, if the Member and Cigna cannot agree. If the parties cannot agree on the individual neutral
arbitrator, the arbitrator will be selected in accordance with JAMS Rule 15 (or any successor rule).
However, in the case of a medical malpractice dispute in which the total amount of damages claimed is fifty thousand dollars ($50,000) or less, the
parties may select a single neutral arbitrator who shall have no jurisdiction to award more than fifty thousand dollars ($50,000). If the parties are
unable to agree on the selection of a neutral arbitrator, the method provided in Section 1281.6 of the CA Code of Civil Procedure should be
utilized.
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Insured by Cigna Health and Life Insurance Company.
Insurance benefits are administered by Oscar Health Administrators. Pharmacy benefits are provided by Express Scripts, Inc. Cigna + Oscar health
insurance contains exclusions and limitations. For complete details on product availability and coverage, please refer to your plan documents or
contact a representative.
Please read this section carefully before signing the application. Submitting this enrollment form electronically is voluntary. Upon receipt of
this form by the Carrier, you will receive an email confirmation. You may opt out of completing this form electronically or receiving
confirmation electronically at any time. To opt out, discontinue filling out this form and inform your representative that you wish to submit a
paper version of the form, which can be found here. If you need to change your email address, please contact your broker or benefit
administrator. Your broker or benefit administrator will need to change your email address of record via business.hioscar.com and re-send
you the invitation to complete your application. At that time, you will be able to sign up with your new email address.
Eligible Employee means:
An active employee of the Employer who works the number of hours per week to be eligible for benefits as defined by the Employer, who
meets the definition of “Eligible Employee” under California. Employment must be verifiable from state or federal wage tax reports;
• An Eligible Employee, as defined above, who enters into employment after the coverage effective date and who completes the group
imposed waiting period for eligibility (if any) and applies for coverage within 30 days of becoming eligible to enroll in coverage;
• Any other class of persons identified by the Employer, provided that written approval of their eligibility is obtained from the
Company(ies); or
• An Eligible Employee, who is eligible for continued coverage under California State or Federal laws
Applicant signature
Printed name
Date (mm/dd/yyyy)
