This preview shows page 1. Sign up to view the full content.
Unformatted text preview: Study USA-HealthCare™ Conﬁr mation of Insurance
The Insurance Company of the State of Pennsylvania
with its principal place of business in New York, NY
Having issued the Policy to SunTrust Bank as Trustee of the Group Insurance Trust
(District of Columbia) (Herein called the Policyholder)
Conﬁr mation I.D. No. 2041034
Travel Assist No. 9912 Insured’s Name / Mailing Address
Zhi Dong Li
2263 Oakland Ave.
Pleasanton, CA 94588
USA Policy No. 9103109
Passport No. G29814542
Total Premium Paid Plan Purchased Name(s) of Insured(s)
Zhi Dong Li $114.00
Expiration Date Effective Date A 1/2/2010 4/1/2011 11:59pm Limits of Coverage
Medical Beneﬁts AD&D Emergency Medical
Evacuation Repatriation of Remains Bedside Visit Plan A $250,000 per incident $5,000 $500,000 $100,000 $2,500 Plan B $300,000 per incident $5,000 $500,000 $100,000 $2,500 Medical Expense Beneﬁts Schedule
In the First Health Network or Outside U.S. Medical Beneﬁt Schedule
Up to $25,000
Plan A $25,000.01 - $250,000
Plan B $25,000.01 - $300,000
Prescription Copay** Out of the First Health Network After a $50
Deductible* /incident After a $150
Deductible*/incident Program Pays Covered Medical Expenses:
80% 70% Program Pays Covered Medical Expenses:
$10 for generic $20 for brand names * The deductible will be waived if medical service is ﬁrst received from the Student Health Center. Otherwise, the
Covered Person must pay the Deductible. The Deductible shall not exceed $250 per Covered Person per Program year. If there is no Student
Health Center, the deductible will be waived only if medical services are received from a First Health Preferred Provider Network member.
** The prescription copay is in addition to the deductible above.
Beneﬁts will be paid at Network level if: 1) treated by a provider who is a member of the First Health Preferred Provider Network; 2) treated for a
Medical Emergency; or 3) treated by a non First Health provider when there is no First Health provider qualiﬁed to provide the care needed within
a 50 mile radius of the Covered Person’s student residence. A Covered Person must receive treatment for an injury or illness within 30 days of the
date of the Injury or Illness.
12/10 Here is your new Medical Insurance I.D. Card.
Carry your I.D. Card at all times. Always present it to your medical service provider.
cut here How to Find A Doctor (In the U.S. Only) Medical Insurance I.D. Card Your Plan offers a preferred provider network of hospitals,
physicians, and other health care providers. Utilizing this
network may decrease your out of pocket costs. Zhi Dong Li
Insured Person ___________________________________
Name of Plan ____________________________________ When you need medical attention, contact First Health at
(888) 685-7774 or online at www.myfirsthealth.com to
obtain a list of Participating Providers.
Providers can call (800) 937-6824. 2041034
Confirmation Number ______________________________
Policy Number ___________________________________
Effective Date ____________________________________
Expiration Date ___________________________________
Insurance underwritten by The Insurance Company of the State of
Pennsylvania. This card does not guarantee health benefits or
coverage. Pre-Certification will not be granted. Insurance Claims and Questions: Emergency Medical Assistance Service: If you or your doctor need to verify coverage, obtain a
claim form, file a claim, or ask about the status of a claim,
contact: To obtain assistance in the event of an extreme emergency
in which immediate emergency medical care is required,
contact the 24-hour assistance service, Travel Assist. Chartis
Accident and Health Claims - TIS Claims Unit
P.O. Box 25987
Shawnee Mission, KS 66225-5987
Mon - Fri: 8:00am to 8:00pm EST Travel Assist can organize all emergency medical
transportations, and provide multilingual assistance.
Call toll free in the U.S. (800) 626-2427 or
collect from outside the U.S. 001-715-295-9817.
12/10 cut here ...
View Full Document
- Spring '09