Susa_DOC_112011 - Study USA-HealthCare™ Description of...

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Unformatted text preview: Study USA-HealthCare™ Description of Coverage 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). 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 Emergency Medical Assistance Service TO OBTAIN ASSISTANCE IN THE EVENT OF A MEDICAL EMERGENCY OR TO FACILITATE MEDICAL CARE, contact the insurance company’s 24-hour assistance service, Travel Assist, located in Houston, Texas. Travel Assist can recommend a local doctor or hospital, verify coverage, organize all emergency medical transportations, and provide multilingual assistance. Call toll free in the U.S. and Canada 1-800-626-2427 or call 0-715-295-9817. If outside the U.S. call collect 0-715-295-9817. Identify yourself as a Study USA-HealthCare™ insured and refer to the Policy Number on your confirmation. ALL EMERGENCY MEDICAL EVACUATIONS AND REPATRIATIONS ARE TO BE ARRANGED BY TRAVEL ASSIST. How to File a Claim You will need to save copies of all receipts. All itemized bills must be submitted to the Insurance Company with a Claim Form. To request a claim form, please contact: Chartis, Accident & Health Claims, Travel Insurance Services Claims Unit, P.O. Box 25987, Shawnee Mission, KS 66225-5987 or call toll free 1-800-551-0824. Written notice of a claim must be made to the Claims Unit within twenty (20) days after the occurrence or commencement if any loss covered by the Policy, or as soon thereafter as is reasonably possible. THE COMPANY HEREBY CERTIFIES that the person(s) named in the Schedule (herein called Insured Person) is insured under and subject to all definitions, exceptions, limitations, and provisions of said Policy; to the extent provided in the Master Policy on file with the Company. The Master Policy constitutes the only agreement under which payments are made. Refund of Premium Premiums received by the Program Marketer/Insurance Company will be considered fully earned and non-refundable. Coverage under this program terminates if a covered Person enters military service and a pro-rata refund will be made from the date a written request is received. Otherwise, no refunds will be made. Summary of Coverage This is a brief description of the Accident and Illness Insurance Program. The exact provisions governing this insurance are contained in the Master Policy underwritten by the Insurance Company of the state of Pennsylvania. A Blanket Accident and Illness Master Policy is on file with the Program Marketer, Travel Insurance Services. The Master Policy shall control in the event of any conflict between this brochure and the Program. Eligibility of Coverage Foreign Students Studying in the U.S.: Individuals under age 66 who have valid visa status in the U.S. and are registered and engaged in academic activities at a US school, college or university; U.S. Registered Students Studying Outside the U.S.: U.S. Permanent Residents under age 66 who are registered with a school, college, or university and engaged in academic activities abroad (excluding home country); Dependents: Spouse and/or children (under age 18) of enrolled students may apply for insurance with the student, or within 31 days of birth, legal adoption, marriage, or arrival in the country of study. Period of Insurance 1. Effective Date of Insurance. Provided the Enrollment Form is submitted and accepted and the required premium is paid, your insurance will become effective at 12:01 a.m. Standard Time on the latest of: -the Master Policy Effective Date; -the date you indicated on the Enrollment Form; or -the date the completed Enrollment Form and premium are received by the Program Marketer. 2. Coverage is renewable as long as the student has continuous coverage and meets eligibility requirements. 3. Termination of Insurance. Your insurance will terminate at 11:59 p.m. Standard Time on the earliest of: -the last day for which your premium has been paid; -the date you cease to be eligible for this insurance; or -the date the Master Policy terminates. Page 1 of 4 11/11 4. Termination of Insurance for Dependents. Your Dependent insurance will terminate on the earliest of: -the last day for which premium for the Dependent has been paid; -the date the Dependent ceases to be a qualified Dependent; or -the date your insurance terminates. within a 50 mile radius of the Covered Person’s student residence. Continuously Insured Any Covered Person who has continuous coverage under this Program from one year to the next shall be covered for conditions first Manifesting themselves while continuously insured. The total amount of benefits payable for an Injury or Illness cannot exceed the Aggregate Maximum per Injury or Illness under this Program. During this Program year, a Covered Person must pay the appropriate premium and submit a completed Renewal Form within 30 days following the end of their current coverage period to avoid a lapse in coverage. This continuously Insured provision will not establish a new benefit period, nor affect any lifetime or other maximum benefits shown for an incurred loss existing during any preceding coverage period. Preferred Provider Network Utilizing the First Health Nationwide Preferred Provider Network will decrease a Covered Person’s out of pocket costs under this Program. Covered Persons may choose to be treated Inside or Outside the First Health Network. For a complete listing of First Health Network participants in the U.S. only, a Covered Person may contact First Health at 1-888-6857774, toll free 24 hours a day, or visit the First Health Web site at www. Medical Expense Benefits Schedule If as the result of an Injury or Illness, a Covered Person incurs medical expenses, We will pay the covered percentage of reasonable and customary charges for the Covered Medical Expenses incurred as described below and subject to the limitations, within 52 weeks from the date of the Injury or Illness or commencement of the first expense up to an Aggregate Maximum of Plan A $250,000 or Plan B $300,000 per Injury or Illness. A Covered Person must receive treatment for an Injury or Illness within 30 days of the date of the Injury or Illness. Medical Benefit Schedule In the First Health Network or Outside U.S. Out of the First Health Network After a $50 Deductible* /incident After a $150 Deductible*/incident Up to $25,000 Program Pays Covered Medical Expenses: 80% 70% Plan A $25,000.01 - $250,000 Plan B $25,000.01 - $300,000 Program Pays Covered Medical Expenses: 70% 100% Insured Pays: $10 for generic $20 for brand names Prescription Copay** Emergency Room Copay** $100 per visit * 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. ** The Emergency Room copay is in addition to the deductible above, and will be waived if admitted to the hospital. 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 Covered Expenses 1. Charges made by a hospital for room and board, floor nursing and other services, including charges for professional services, except personal services of a non-medical nature, provided, however, that expenses do not exceed the hospital’s average charge for semiprivate room and board accommodation, subject to a maximum of $300 per day, or two (2) times the average semi-private room charge if confinement to an intensive care unit is required, or the actual charge for an intensive care unit made by the servicing hospital, whichever is less; Intensive Care Unit (ICU) is covered up to $500 maximum per day. 2. Charges made for diagnosis, treatment and surgery by a physician. 3. Charges made for the cost and administration of anesthetics. 4. Charges for medication, x-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood transfusions, iron lungs, and medical treatment. 5. Charges for physiotherapy, if recommended by a physician for the treatment of a specific disablement and administered by a licensed physiotherapist. 6. Dressings, drugs and medicines that can only be obtained upon a written prescription of a physician or surgeon. 7. Dental Treatment: The Program will pay for treatment of Injury to sound natural teeth as any other injury up to $250.00 per tooth to a maximum of $1,000 per Injury. 8. Therapeutic Termination of Pregnancy: The Program will pay on the same basis as any other Illness up to a $500.00 maximum. 9. Chiropractic expenses: When it is medically necessary, the Program will pay up to a maximum of $35.00 per visit up to a maximum of 3 visits per week, for a maximum benefit of $1,000 per year. 10. Charges for the Newborn baby hospital nursery expenses up to the maximum of $500 per day. 11. Charges for the Outpatient Surgery Facility expenses up to the maximum of $250 per day. Emergency Medical Evacuation Benefit If Injury or Illness commencing during the Period of Coverage requires emergency evacuation to either the nearest medical facility where appropriate medical treatment can be obtained, or to the Country of Residence, all expenses incurred are covered up to a limit of $500,000. An emergency evacuation must be recommended by a legally licensed physician who certifies that the severity of Injury or Illness necessitates such emergency evacuation and agreed to by you or your representative. Arrangements must be made by Travel Assist. Bedside Visit The Company will pay the cost of a round trip economy airline ticket, up to a maximum of $2,500, to bring one person chosen by the Insured to and from the hospital or other medical facility where the Insured is confined when, in the opinion of a medical practitioner acceptable to the Company, such a visit is necessary due to a bodily injury or illness which constitutes an immediate danger to life. Travel Assist must make all arrangements for any benefit to be payable. Accidental Death and Dismemberment If a Covered Person suffers an Injury which results directly in any of the losses shown in the Table of Losses below, such Covered Person will be entitled to the benefits shown if: 1) the accidental bodily injury or injuries sustained by the Covered Person is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while coverage is in force and not while the Covered Person is in his Home Country; and 2) the loss was suffered within 365 days of the accident. For Loss of:................................................................. Benefit Amount Life ........................................................................................... $5,000 Both Hands, Both Feet or Sight of Both Eyes ......................... $5,000 Either One Hand or One Foot and Sight of One Eye .............. $5,000 One Hand and One Foot ......................................................... $5,000 Page 2 of 4 11/11 Either Hand or Foot ................................................................. $2,500 Sight of One Eye ..................................................................... $2,500 Loss means: 1) with regard to hands and feet, dismemberment by severance through or above the wrist or ankle joints; and 2) with regard to eyes, entire and irrecoverable loss of sight. Payment will be made for only the largest loss, and will be in addition to any other benefits payable under this Program. This benefit does not cover: 1. Any loss, fatal or non-fatal, caused by or resulting from: a) Intentionally self-inflicted injury, suicide while sane or attempted suicide while insane; b) War or any act of war, declared or undeclared, or service in the military, naval or air service of any country; c) Piloting or acting as a crew member, or riding in any aircraft except as a fare paying passenger on a scheduled airline; or d) The insured being under the influence of drugs (unless taken under the advice of a physician and within the amounts prescribed by a physician) or intoxicants of any type including Alcohol. 2. Any loss, fatal or non-fatal, caused by or resulting from: a) Illness, disease, pregnancy, childbirth, miscarriage; or any bacterial infection other than one occurring from an accidental cut or wound; or b) Hernia. Mental or Nervous Disorders and Alcohol and Substance Abuse Benefits This Program includes treatment for Mental or Nervous Disorders and Alcohol and Substance Abuse as follows: When confined as an inpatient or when treated on an outpatient basis, the Program will pay the lesser of: 1) The Usual, Reasonable and Customary Charge incurred for the first 30 days of hospital confinement per Program year; or 2) 90% of the Usual, Reasonable and Customary Charge incurred up to a limit of $5,000 ($10,000 for foreign students studying in the U.S.). Repatriation of Remains Benefit If Injury or Illness commencing during the Period of Coverage results in death, all reasonable expenses incurred for preparation and return of the remains to the Country of Residence will be paid up to a limit of $100,000. Arrangements must be made by Travel Assist. Exclusions This program does not cover loss caused by or resulting from, nor is any premium charged for, the following expenses: 1. Pre-Existing Conditions. A Pre-Existing Condition is defined as any injury or illness or condition which was contracted or which first manifested itself, or for which a licensed physician was consulted, or for which treatment or medication was prescribed, within 6 months prior to the effective date of the Covered Person’s coverage under this Program. Pre-existing Conditions shall be excluded from coverage for a period of 6 months following the effective date of coverage under this Program. A Covered Person must be continuously insured. Conception of pregnancy must occur after the effective date of the Covered Person's coverage. 2. Expenses in excess of Usual, Reasonable and Customary Charges; 3. Services normally provided without charge by the College’s health service, infirmary, or Hospital, or by health care providers employed by the College; or for any expenses for services rendered elsewhere which are available at the Student Health Service, infirmary, or hospital except in cases of Medical Emergency; 4. Eyeglasses, contact lenses, hearing aids, or prescriptions, examinations thereof, radical keratotomy or laser eye surgery to correct vision impairment; 5. Injury due to participation in a riot; 6. Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare paying passenger in an aircraft, operated by a scheduled airline maintaining regular published schedules on a regularly established route; 7. Injury sustained or Illness contracted while in the service of the Armed Forces of any country; 8. Treatment of mental or nervous disorders, except as specifically provided; 9. Elective treatment or elective surgery, except as specifically provided; 10.Treatment provided in a government Hospital unless there is a legal obligation to pay such charges in the absence of insurance; 11. Expenses incurred after the date of insurance termination for a Covered Person; 12.Congenital conditions, except as specifically provided for newborn infants; 13.Expenses incurred for services or supplies which are experimental or investigative in nature; including the treatment, procedure, facility, equipment, drugs usage, device or supplies; 14.Professional services rendered by a member of the Covered Person’s family or anyone who lives with the Covered Person; 15.Expenses incurred for services and supplies not: a) medically necessary for the diagnosis or treatment of any Injury or Illness; and b) recommended by the attending Physician; 16.Routine physicals; 17.Dental care, except as the result of injury to natural teeth caused by accident, any treatment identified as Temporomandibular Joint Dysfunction (TMJ); 18.Expenses incurred in connection with weak, strained or flat feet, corns, calluses, bunions, or toenails; 19.Expenses incurred for plastic or cosmetic surgery unless they result directly from an injury that necessitated medical treatment within 24 hours of the accident; 20.Expenses incurred as a result of diagnostic or surgical procedures in connection with infertility unless caused by an Injury or Illness; 21.Expenses incurred in connection with birth control, sterilization, or sterilization reversal, including surgical procedures and devices; 22.Expenses covered under any occupational benefit Policy, Workers’ Compensation Act or similar law, automobile medical payments or Nofault plans, public assistance programs, government plan or any other valid and collectible insurance; 23.War or any act of war, whether declared or undeclared; 24.Committing or attempting to commit an assault or felony, fighting or brawling, except in self-defense; 25.Suicide or intentionally self-inflicted injury while sane or insane; 26.Claims arising out of participation in interscholastic, intercollegiate or professional sporting events; racing; speed contests; skin diving; skydiving; mountaineering (where ropes or guides are customarily used), para-sailing; hang gliding; bungee jumping; bob-sledding; travel on a snow mobile or ATV; any two or three wheeled motor vehicle; or private air travel, to include ballooning and ultra-light aircraft; 27.Expenses incurred while the Covered Person is intoxicated or under the influence of any drug unless taken under the advice of a licensed Physician; 28.Expenses resulting from a motor vehicle accident if the Covered Person is not properly licensed to operate the motor vehicle within the jurisdiction in which the accident takes place (this exclusion will not apply to passengers if they are insured under this Program); 29.Expenses for circumcision; tubal ligation; vasectomy; breast reduction; breast implants; sexual reassignment surgery; orthognathic surgery, including mandibular retrognathia; learning disabilities; smoking cessation; hair removal, replacement or hair growth; organ transplants; 30.Pregnancy or childbirth for a dependent child of an Insured Student; 31.Expenses greater than $1,000 for Injuries or Illnesses incurred in the Insured Person's Country of Permanent Residence and after 30 days from the date the Insured entered the Country of Permanent Residence. Page 3 of 4 11/11 Services Emergency Travelers Assistance Services • 24-hour verification of medical coverage for hospitals and physicians. • 24-hour medical care location service. • Medical case monitoring, arranging communication between patient, family, physicians, employer, consulate or embassy. • Emergency medical transportation arrangements. • Emergency message service for medical situations. • Multilingual services. • 24-hour contact for legal emergencies. • Legal referral, to help you locate a consular official or attorney. Concierge Services • Restaurant referrals and reservations - Worldwide dining referrals and reservations made on behalf of the customer, based on availability. • Event Ticketing - Assistance with obtaining tickets to sporting, theater, concert and other events, based on availability. • Ground transportation coordination – Coordination of car or limo arrangements including transportation to and from the airport, hotel, meetings and more. • Golf tee time reservations and referrals - Assistance with scheduling tee times and making course recommendations, based on availability. • Wireless device assistance- Assistance with cell phones, personal digital assistants (PDAs) and other wireless devices, such as locating carrier stores, technicians, repair shops, replacement services when device is lost, stolen, or inoperable • Latest worldwide weather and ski reports- 24/7 update on destination weather as well as ski conditions throughout the world • Floral Services - Coordination of flower delivery for birthdays, anniversaries, holidays and other special occasions. • Private air charter assistance- Coordination with Private air charters to gain access, availability and booking. • Cruise charter assistance- Assistance with establishing availability and booking of cruise charters. • Latest sports scores- 24/7 updates on sports scores. • Find, wrap, and deliver one-of-a-kind gifts- Assistance in finding unique gifts for friends and family, including gift wrapping and delivery • Movie and theater information- Assistance with obtaining information about movie or theater events playing within a specific area. Travel Assist also obtains the tickets to theater or movie events, based on availability. • Latest stock quotes- Up-to-the-minute stock quotes • Special occasion reminders and gift ideas- Never miss a birthday, anniversary or special day while traveling. All special occasions are kept within Travel Guard Client Services database and a reminder is sent 48 hours prior to the day. Coordination of finding unique gifts for friends and family, including gift wrapping and delivery are included. • Lottery results- Up-to-the-minute lottery results • Local activity recommendations- Worldwide local activity referrals and reservations made on behalf of customer, based on availability ID Theft Service The Company will provide the Services within the United States, except for New York. The following Services will be provided to Eligible Person(s): • Use of the Identity Theft Customer Service Center, • A copy of the Identity Theft Recovery Kit if requested, and • Restoration Services. As Restoration Services consists of one or more of the following services to be performed for an Eligible Person in the event of an Identity Theft or Account Takeover that first occurs while the policy is in effect: 1. Provide Eligible Person with a package of information which includes a description of the resolution process, educational articles, and guidance for avoiding future complications. 2. Notify the three major credit bureaus, and the Eligible Person's affected creditors, financial institutions, and utility providers of the identity fraud. 3. Provide assistance with filing a police report. 4. When appropriate, provide assistance with requesting that a fraud alert be placed on the Eligible Person’s credit files and affected credit accounts. 5. When necessary, notify merchants that a fraudulent transaction occurred. 6. When appropriate, collect information regarding misuse of the Eligible Person’s accounts. 7. Create and maintain a case file to document the identity fraud. 8. Review the Eligible Person’s credit files with the Eligible Person to determine the accuracy of the file and potential areas of fraud. 9. When appropriate, provide assistance with obtaining and reviewing the Eligible Person's Social Security Personal Earnings and Benefits Statement. 10. Provide information to the Federal Trade Commission and to other government agencies as appropriate. 11. Research and investigate potential damage to Eligible Person's identity. 12. Other assistance as the Company might reasonably be able to offer Eligible Persons on a case by case basis as determined by the provider of the Services in its sole discretion. Definitions Account Takeover – “Account Takeover” means the takeover by a third party of one or more existing deposit accounts, credit card accounts, debit card accounts, ATM cards, utility or telecommunication accounts or lines of credit in the name of an eligible person. An Eligible Person will receive service due to an Account Takeover that occurs while the policy is in effect. Identity Theft – “Identity Theft” means the creation of one or more new financial service accounts, or new identities in public records (such as a driver’s license) or elsewhere, by a third party in the name of and without the knowledge of the victim, to commit fraud or other crimes and/or to disguise the third party’s true identity. An Eligible Person will receive Service due to an Identity Theft that occurs while the policy is in effect. Identity Theft Customer Service Center – Identity Theft Customer Service Center means that live, trained identity theft service representatives will answer Eligible Persons’ calls on a 24 X 7 basis. Service representatives will provide assistance to the Eligible Person in restoring his/her identity by educating the Eligible Person on the process required, providing pertinent contact information for the credit reporting agencies, Federal Trade Commission and other organizations as indicated. Service representatives will collect all required data to document the service call and provide follow up. Identity Theft Recovery Kit- Identity Theft Recovery Kit means a booklet that explains in detail the process of identity theft recovery, and also includes form letters that can be sent to credit bureaus, financial institutions and government agencies to assist an Eligible Person in combating identity theft. Page 4 of 4 11/11 ...
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