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
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
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
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
-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.
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:
70% Plan A $25,000.01 - $250,000
Plan B $25,000.01 - $300,000 Program Pays Covered Medical Expenses:
$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
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.
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
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)
Mental or Nervous Disorders and Alcohol and Substance
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.
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
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
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
12.Congenital conditions, except as specifically provided for newborn
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;
17.Dental care, except as the result of injury to natural teeth caused
by accident, any treatment identified as Temporomandibular Joint
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
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
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
• 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.
• Restaurant referrals and reservations - Worldwide dining referrals
and reservations made on behalf of the customer, based on
• 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
• 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
• 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
• 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
• 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
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
5. When necessary, notify merchants that a fraudulent transaction
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
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
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.
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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- Spring '09