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201012011547170731 - Study USA-HealthCare™ Confir mation...

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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: 70% 100% Insured Pays: $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 ___________________________________ A 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 ______________________________ 9103109 Policy Number ___________________________________ 1/2/2010 Effective Date ____________________________________ 4/1/2011 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 (800) 551-0824 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 ...
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