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On April 25, 2001, Mr. Albers completed a preprinted
application form entitled “Application for Individual Health &
Life Insurance” (Mr. Albers’s Wellmark application). In that
application, Mr. Albers applied to Wellmark/Blue Cross Blue
Shield of South Dakota (Wellmark) for a so-called Blue Select
health insurance policy to cover himself, Ms. Albers, and their
dependent children. In Mr. Albers’s Wellmark application, Mr.
Albers identified himself as “Applicant”, Ms. Albers as “Spouse”,
and each of their children as a “Dependent”. The portion of Mr.
Albers’s application entitled “Enrollment Information” stated in
pertinent part:
1. The Plan I am applying for is: * CLASSIC BLUEBLUE SELECT Are you also applying for the
(PLEASE CIRCLE ONE) . Plan I Plan II$500 $750 $1,000Supplemental Accident Option?
+ Plan III Plan IV $2,500 $5,0009Yes :No N/A on Plan A
* Plan A Plan B or B
2. This request for coverage is for: (check all that apply)3. This application is for: (check all that apply)
:Self :Spouse :Child(ren) :New Enrollment 9Change 9Adding/Removing
Dependents
4. Indicate how you wish to be billed: (check all that apply)
9 Monthly [Automatic Account Withdrawal required; complete form M-3506(U)] 9Quarterly :Semi-annually 9Annually
9 Automatic Account Withdrawal (complete form M-3506(U) Authorization for Automatic Account Withdrawal)
5. The amount you are submitting for health insurance is: $229.10 (Make check payable to Wellmark Blue Cross and Blue
Shield of South Dakota)
* * * * * * *
Is any portion of the premium or benefits paid by or on behalf of the small group employer? Yes (reason) _______ :No
Is the health benefit plan part of a plan or program for purposes of Section 125 or 106 of the IRS code? 9Yes :No
* * * * * * *
7. Creditable Coverage. Does any person named on this application have health care coverage now or did they have it within
the last 63 days? 9No :Yes, complete the following:
Type of Policy - Company or
Individual Covered IndividualEffective DateTermination DateInsurance CompanyID Number
Family Ind. All 7-8 yrs. issue Am. Republic
4Mr. Albers circled “$2,500” under the “Blue Select” plan
for which he was applying.
5The word that appeared before the word “issue” is not
legible.
6The “ID Number” shown was Mr. Albers’s Social Security
number.
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Last modified: November 10, 2007