Executive Health Plan

YOUR
GROUP INSURANCE
PLAN


GENERAL MILLS EXECUTIVE HEALTH PLAN


CERTIFICATE OF COVERAGE


This certifies that the employee named below is entitled to the benefits described in this certificate, provided the eligibility and effective date requirements of the plan are satisfied.


Group Policy No.____ Certificate No.____ Effective Date __________


Issued To ________________________________________________________


This CERTIFICATE OF COVERAGE replaces any CERTIFICATE OF COVERAGE previously issued under the above Plan or under any other Plan providing similar or identical benefits issued to the Planholder.


B110.0031-R


- -------------------------------------------------------------------------------- TABLE OF CONTENTS - --------------------------------------------------------------------------------


COMPLAINT NOTICE .......................................................... 1


GENERAL PROVISIONS
Limitation of Authority ................................................ 3
Incontestability ....................................................... 3
Examination and Autopsy ................................................ 4
Accident and Health Claims Provisions .................................. 4
Coordination Between Continuation Sections ............................. 5
An Important Notice About Continuation Rights .......................... 5


YOUR CONTINUATION RIGHTS
Federal Continuation Rights ............................................ 6
Important Notice ....................................................... 11
Group Health Continuation Rights ....................................... 11


YOUR DEPENDENT CONTINUATION RIGHTS
Important Notice ....................................................... 13
Your Group Health Benefits Continuation Rights ......................... 13


ELIGIBILITY FOR MAJOR MEDICAL COVERAGE
Employee Coverage ...................................................... 15
Dependent Coverage ..................................................... 16


CERTIFICATE AMENDMENT ..................................................... 20


MAJOR MEDICAL HIGHLIGHTS .................................................. 22


MAJOR MEDICAL EXPENSE INSURANCE
Benefit Provision ...................................................... 23
Extended Major Medical Benefits ........................................ 24
Covered Charges ........................................................ 25
Charges Covered With Special Limitations ............................... 29
Exclusions ............................................................. 34
Hospital Bill Audit Bonus .............................................. 35
Converting This Group Health Insurance ................................. 36


ELIGIBILITY FOR DENTAL COVERAGE
Employee Coverage ...................................................... 38
Dependent Coverage ..................................................... 39


CERTIFICATE AMENDMENT ..................................................... 42


DENTAL HIGHLIGHTS ......................................................... 44


DENTAL EXPENSE INSURANCE
Covered Charges ........................................................ 45
Pre-Treatment Review ................................................... 45
Benefits From Other Sources ............................................ 46
The Benefit Provision - Qualifying For Benefits ........................ 46
After This Insurance Ends .............................................. 47
Exclusions ............................................................. 47
List of Covered Dental Services ........................................ 49
Group I - Preventive Dental Services ................................... 49


TABLE OF CONTENTS (CONT.) - --------------------------------------------------------------------------------
Group II - Basic Dental Services ....................................... 50
Group III - Major Dental Services ...................................... 52
Group IV - Orthodontic Services ........................................ 53


ELIGIBILITY FOR PRESCRIPTION DRUG COVERAGE
Employee Coverage ...................................................... 54
Dependent Coverage ..................................................... 55


CERTIFICATE AMENDMENT ..................................................... 58


PRESCRIPTION DRUG EXPENSE INSURANCE
Covered Drugs .......................................................... 60
Dispensing Limits ...................................................... 60
Benefit Provisions ..................................................... 60
Extended Benefit ....................................................... 61
Employer Liability ..................................................... 61
Exclusions ............................................................. 61


COORDINATION OF BENEFITS .................................................. 63


HOW THIS PLAN INTERACTS WITH MEDICARE
Medicare Eligibility By Reason Of Age .................................. 66
Medicare Eligibility By Reason Of Disability ........................... 66
Medicare Eligibility By Reason Of End Stage Renal Disease .............. 67
Other People Who Are Eligible For Medicare ............................. 68


WORKER'S COMPENSATION ..................................................... 69


GLOSSARY .................................................................. 70


SUMMARY PLAN DESCRIPTION SUPPLEMENT TO CERTIFICATE ........................ 78


STATEMENT OF ERISA RIGHTS
The Guardian's Responsibilities ........................................ 81
Claims Procedure ....................................................... 81
Termination of This Group Plan ......................................... 82


- -------------------------------------------------------------------------------- COMPLAINT NOTICE - --------------------------------------------------------------------------------


This notice is to advise you that should any complaints arise regarding this insurance you may contact the following:


The Guardian Sales Office
8300 Norman Center Drive
Suite 815
Bloomington, Minnesota 55437
Telephone: (612) 835-3470
(800) 814-1399
Fax: (612) 835-6886


* * * * *


Illinois Department of Insurance
Consumer Division or Public Services Section
Springfield, Illinois 62767


B120.0007-R


P.1


- -------------------------------------------------------------------------------- GENERAL PROVISIONS - --------------------------------------------------------------------------------


As used in this booklet:


"Accident and health" means any dental, hospital, major
medical, out-of-network point-of-service, prescription
drug, surgical or vision care insurance provided by this
PLAN.


"Covered person" means an EMPLOYEE or a dependent
insured by this PLAN.


"Employer" means the EMPLOYER who purchased this PLAN.


"Our," "The Guardian," "us" and "we" mean The Guardian
Life Insurance Company of America.


"Plan" means the Guardian PLAN of group insurance
purchased by your EMPLOYER.


"You" and "your" mean an EMPLOYEE insured by this PLAN.


B160.0002-R


LIMITATION OF AUTHORITY - --------------------------------------------------------------------------------


No person, except by a writing signed by the President,
a Vice President or a Secretary of The Guardian, has the
authority to act for us to: (a) determine whether any
contract, plan or certificate of insurance is to be
issued; (b) waive or alter any provisions of any
insurance contract or plan, or any requirements of The
Guardian; (c) bind us by any statement or promise
relating to any insurance contract issued or to be
issued; or (d) accept any information or representation
which is not in a signed application.


B160.0004-R


INCONTESTABILITY - --------------------------------------------------------------------------------


This PLAN is incontestable after two years from its date
of issue, except for non-payment of premiums.


No statement in any application, except a fraudulent
statement, made by a person insured under this PLAN
shall be used in contesting the validity of his
insurance or in denying a claim for a loss incurred, or
for a disability which starts, after such insurance has
been in force for two years during his lifetime.


If this PLAN replaces a plan your EMPLOYER had with
another insurer, we may rescind the EMPLOYER'S PLAN
based on misrepresentations made by the EMPLOYER or an
EMPLOYEE in a signed application for up to two years
from the effective date of this PLAN.


B160.0003-R


P.3


EXAMINATION AND AUTOPSY - --------------------------------------------------------------------------------


We have the right to have a DOCTOR of our choice examine
the person for whom a claim is being made under this
PLAN as often as we feel necessary. And we have the
right to have an autopsy performed in the case of death,
where allowed by law. We'll pay for all such
examinations and autopsies.


B160.0006-R


ACCIDENT AND HEALTH CLAIMS PROVISIONS - --------------------------------------------------------------------------------


Your right to make a claim for any ACCIDENT AND HEALTH
benefits provided by this PLAN, is governed as follows:


PROOF OF LOSS We'll furnish you with forms for filing proof of loss
within 15 days of receipt of notice. But if we don't
furnish the forms on time, we'll accept a written
description and adequate documentation of the INJURY or
SICKNESS that is the basis of the claim as proof of
loss. You must detail the nature and extent of the loss
for which the claim is being made. You must send us
written proof within 90 days of the loss.


LATE NOTICE OF PROOF We won't void or reduce your claim if you can't send us
notice and proof of loss within the required time. But
you must send us notice and proof as soon as reasonably
possible.


PAYMENT OF BENEFITS We'll pay all other ACCIDENT AND HEALTH benefits to
which you're entitled as soon as we receive written
proof of loss


We pay all ACCIDENT AND HEALTH benefits to you, if
you're living. If you're not living, we have the right
to pay all ACCIDENT AND HEALTH benefits, except
dismemberment benefits, to one of the following: (a)
your estate; (b) your spouse; (c) your parents; (d) your
children; (e) your brothers and sisters; and (f) any
unpaid provider of health care services. See "Your
Accidental Death and Dismemberment Benefits" for how
dismemberment benefits are paid.


When you file proof of loss, you may direct us, in
writing, to pay health care benefits to the recognized
provider of health care who provided the covered service
for which benefits became payable. We may honor such
direction at our option. But we can't tell you that a
particular provider must provide such care. And you may
not assign your right to take legal action under this
PLAN to such provider.


LIMITATIONS OF ACTIONS You can't bring a legal action against this PLAN until
60 days from the date you file proof of loss. And you
can't bring legal action against this PLAN after three
years from the date you file proof of loss.


WORKERS' COMPENSATION The ACCIDENT AND HEALTH benefits provided by this PLAN
are not in place of, and do not affect requirements for
coverage by Workers' Compensation.


B160.0005-R


P.4


COORDINATION BETWEEN CONTINUATION SECTIONS - --------------------------------------------------------------------------------


A covered person may be eligible to continue his group
health benefits under this plan's "Federal Continuation
Rights" section and under other continuation sections of
this plan at the same time. If he chooses to continue
his group health benefits under more than one section,
the continuations: (a) start at the same time; (b) run
concurrently; and (c) end independently, on their own
terms.


A covered person covered under more than one of this
plan's continuation sections: (a) will not be entitled
to duplicate benefits; and (b) will not be subject to
the premium requirements of more than one section at the
same time.


B240.0044-R


AN IMPORTANT NOTICE ABOUT CONTINUATION RIGHTS - --------------------------------------------------------------------------------


The following "Federal Continuation Rights" section may
not apply to the employer's plan. The employee must
contact his employer to find out if: (a) the employer is
subject to the "Federal Continuation Rights" section,
and therefore; (b) the section applies to the employee.


B240.0064-R


P.5


- -------------------------------------------------------------------------------- YOUR CONTINUATION RIGHTS - --------------------------------------------------------------------------------


FEDERAL CONTINUATION RIGHTS - -------------------------------------------------------------------------------- IMPORTANT NOTICE This section applies only to any dental, out-of-network
point-of-service medical, major medical, vision care or
prescription drug coverages which are part of this plan.
In this section, these coverages are referred to as
"group health benefits".


This section does not apply to coverages which apply to
loss of life, or to loss of income due to disability.
These coverages cannot be continued under this section.


Under this section, "qualified continuee" means any
person who, on the day before any event which would
qualify him or her for continuation under this section,
is covered for group health benefits under this plan as:
(a) an active, covered employee; (b) the spouse of an
active, covered employee; or (c) the dependent child of
an active, covered employee. A child born to, or adopted
by, the covered employee during a continuation period is
also a qualified continuee. Any other person who becomes
covered under this plan during a continuation provided
by this section is not a qualified continuee.


CONVERSION Continuing the group health benefits does not stop a
qualified continuee from converting some of these
benefits when continuation ends. But, conversion will be
based on any applicable conversion privilege provisions
of this plan in force at the time the continuation ends.


IF YOUR GROUP HEALTH BENEFITS END If your group health benefits end due to your
termination of employment or reduction of work hours,
you may elect to continue such benefits for up to 18
months, if you were not terminated due to gross
misconduct.


The continuation: (a) may cover you or any other
qualified continuee; and (b) is subject to "When
Continuation Ends".


EXTRA CONTINUATION FOR DISABLED QUALIFIED CONTINUEES If a qualified continuee is determined to be disabled
under Title II or Title XVI of the Social Security Act
on or during the first 60 days after the date his or her
group health benefits would otherwise end due to your
termination of employment or reduction of work hours, he
or she may elect to extend his or her 18 month
continuation period explained above for up to an extra
11 months.


To elect the extra 11 months of continuation, the
qualified continuee must give your employer written
proof of Social Security's determination of his or her
disability before the earlier of: (a) the end of the 18
month continuation period; or (b) 60 days after the date
the qualified continuee is determined to be disabled.
If, during this extra 11 month continuation period, the
qualified continuee is determined to be no longer
disabled under the Social Security Act, he or she must
notify your employer within 30 days of such
determination, and continuation will end, as explained
in "When Continuation Ends".


This extra 11 month continuation is subject to "When
Continuation Ends".


P.6


FEDERAL CONTINUATION RIGHTS (CONT.) - --------------------------------------------------------------------------------


An additional 50% of the total premium charge also may
be required from the qualified continuee by your
employer during this extra 11 month continuation period.


B235.0063-R


IF YOU DIE WHILE INSURED If you die while insured, any qualified continuee whose
group health benefits would otherwise end may elect to
continue such benefits. The continuation can last for up
to 36 months, subject to "When Continuation Ends".


B235.0075-R


IF YOUR MARRIAGE ENDS If your marriage ends due to legal divorce or legal
separation, any qualified continuee whose group health
benefits would otherwise end may elect to continue such
benefits. The continuation can last for up to 36 months,
subject to "When Continuation Ends".


IF A DEPENDENT LOSES ELIGIBILITY If a dependent child's group health benefits end due to
his or her loss of dependent eligibility as defined in
this plan, other than your coverage ending, he or she
may elect to continue such benefits. However, such
dependent child must be a qualified continuee. The
continuation can last for up to 36 months, subject to
"When Continuation Ends".


CONCURRENT CONTINUATIONS If a dependent elects to continue his or her group
health benefits due to your termination of employment or
reduction of work hours, the dependent may elect to
extend his or her 18 month or 29 month continuation
period to up to 36 months, if during the 18 month or 29
month continuation period, either: (a) the dependent
becomes eligible for 36 months of group health benefits
due to any of the reasons stated above; or (b) you
become entitled to Medicare.


The 36 month continuation period starts on the date the
18 month continuation period started, and the two
continuation periods will be deemed to have run
concurrently.


SPECIAL MEDICARE RULE If you become entitled to Medicare before a termination
of employment or reduction of work hours, a special rule
applies for a dependent. The continuation period for a
dependent, after your later termination of employment or
reduction of work hours, will be the longer of: (a) 18
months from your termination of employment or reduction
of work hours; or (b) 36 months from the date of your
earlier entitlement to Medicare. If Medicare entitlement
occurs more than 18 months before termination of
employment or reduction of work hours, this special
Medicare rule does not apply.


THE QUALIFIED CONTINUEE'S RESPONSIBILITIES A person eligible for continuation under this section
must notify your employer, in writing, of: (a) your
legal divorce or legal separation from your spouse; or
(b) the loss of dependent eligibility, as defined in
this plan, of an insured dependent child.


Such notice must be given to your employer within 60
days of either of these events.


B235.0077-R


P.7


FEDERAL CONTINUATION RIGHTS (CONT.) - -------------------------------------------------------------------------------- YOUR EMPLOYER'S RESPONSIBILITIES Your employer must notify the qualified continuee, in
writing, of: (a) his or her right to continue this
plan's group health benefits; (b) the monthly premium he
or she must pay to continue such benefits; and (c) the
times and manner in which such monthly payments must be
made.


Such written notice must be given to the qualified
continuee within 14 days of: (a) the date a qualified
continuee's group health benefits would otherwise end
due to your death or your termination of employment or
reduction of work hours; or (b) the date a qualified
continuee notifies your employer, in writing, of your
legal divorce or legal separation from your spouse, or
the loss of dependent eligibility of an insured
dependent child.


YOUR EMPLOYER'S LIABILITY Your employer will be liable for the qualified
continuee's continued group health benefits to the same
extent as, and in place of, us, if: (a) he or she fails
to remit a qualified continuee's timely premium payment
to us on time, thereby causing the qualified continuee's
continued group health benefits to end; or (b) he or she
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