2013-202859-2 ayusa flyer-v12_benefit summary

International Injury and Sickness
Insurance Plan for
Ayusa Participants
Ayusa SP is pleased to offer an Injury and Sickness Insurance Plan underwritten by Student Resources (SPC) Ltd. All eligible participants are automatically enrolled on a mandatory basis.
Student Resources (SPC) Ltd., aUnitedHealth Group Company, Highlights of the Coverage and Services
offered by Student Resources (SPC) Ltd. are:
No Maximum Dollar Limit for Covered Medical Expenses.
Covered Medical Expenses for Preferred Providers are payable at 100% of Preferred Allowance and Out of Network benefits are payable at 100% of Usual and Customarycharges (all benefits are subject to satisfaction of the Deductible, specific benefit limitations, maximums and Copays as described in the policy).
right for you before you enroll.
The plan brochure provides Prescription Drug Benefits: 100% of Usual and Customary Charges.
U.S. citizens are not eligible for this insurance coverage as an Insured or a Dependent.
Coverage available for eligible Dependents, including Domestic Partners.
The Preferred Provider Network for this plan is UnitedHealthcare Options PPO. Preferred Providers can be found using the following link, http://www.uhcsr.com/lookupredirect.aspx?delsys=01 FrontierMEDEX – International Participants are covered worldwide except in their home Online Services: Student Resource (SPC) Ltd. Insureds have online access to their claims status, EOBs, ID Cards, network providers, correspondence and coverage account informationby logging in to My Account at www.uhcsr.com/myaccount. To create an online account, select the “create My Account Now” link and follow the simple, onscreen directions. All you need is your 7-digit Insurance ID number or the email address on file. Insureds can also visit our mobile site at my.uhcsr.com to access an electronic ID card.
PRE-EXISTING CONDITION means: 1) the existence of symptoms which would cause an
ordinarily prudent person to seek diagnosis, care or treatment within the 12 months immediately prior to the Insured's Effective Date under the policy; or, 2) any condition which originates, isdiagnosed, treated or recommended for treatment within the 12 months immediately prior to the Insured's Effective Date under the policy.
provisions, limitations, exclusions,and qualifications of your insurancePlan.
Travel Benefits and Personal Liability*
All Coverages and Benefits are in U.S. Dollar Amounts.
$3,000 - Maximum Benefit per article $500 combined Maximum $1,000 forjewelry, furs, watches, personal computers, cameras Liability
*Travel Benefits and Personal Liability are provided to all participants enrolled in this Plan. These plans are underwritten
by Lloyds of London.
BAGGAGE/PERSONAL EFFECTS
We will pay for loss, theft or damage to baggage and personal effects that accompany You on Your Trip. This coverage is secondaryto any other coverage.
TRIP INTERRUPTION
We will pay to return You Home if a Family Member suffers a life-threatening Sickness, Accidental Injury or death. All transportationin connection with a Trip Interruption must be pre-approved and arranged by the assistance provider.
PERSONAL LIABILITY
We will pay on Your behalf all sums that You become legally obligated to pay as the result of Damages from an Incident that wasreported during the Policy Term. Incident means any act or omission committed by You during the Policy Term which unexpectedly,unintentionally, and suddenly results in Bodily Injury, Property Damage or Personal Injury to a third party. Please note the above is just a summary of benefits and is not Your final fulfillment document. Please refer to
www.uhcsr.com/ayusa for a complete copy of the terms and conditions including any exclusions that apply to each benefit.
EXCLUSIONS AND LIMITATIONS:
No benefits will be paid for: a) loss or expense caused by, contributed to, or 36. Nuclear, chemical or biological Contamination, whether direct or resulting from; or b) treatment, services or supplies for, at, or related to any indirect. “Contamination” means the contamination or poisoning of people by nuclear and/or chemical and/or biological substances 37. Organ transplants, including organ donation; 38. Orthoptics, visual therapy or visual eye training; 4. Addiction, such as: nicotine addiction; and caffeine addiction; non- 39. Outpatient Physiotherapy; except for a condition that required surgery chemical addiction, such as: gambling, sexual, spending, shopping, or Hospital Confinement: 1) within the 90 days immediately preceding such Physiotherapy; or 2) within the 90 days immediately following the 5. Autistic disease of childhood, hyperkinetic syndromes, milieu therapy, attending Physician's release for rehabilitation; learning disabilities, behavioral problems, intensive behavioral 40. Participation in a riot or civil disorder; commission of or attempt to therapies, such as applied behavioral analysis; parent-child problems, attention deficit disorder, conceptual handicap, developmental delay 42. Prescription Drugs, services or supplies as follows: a) Therapeutic devices or appliances, including: hypodermic 7. Charges and all costs related to or arising from or in connection with needles, syringes, support garments and other non-medical all trips to the host country undertaken for the purpose of securing substances, regardless of intended use, except as specifically b) Birth control and/or contraceptives, oral or other, whether medication or device, regardless of intended use; c) Immunization agents, biological sera, blood or blood products 12. Cosmetic procedures, except cosmetic surgery required to correct an d) Drugs labeled, “Caution - limited by federal law to investigational Injury for which benefits are otherwise payable under this policy; 13. Custodial Care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, or places mainly for domiciliary or Drugs used to treat or cure baldness; anabolic steroids used for Custodial Care; extended care in treatment or substance abuse facilities for domiciliary or Custodial Care; g) Anorectics - drugs used for the purpose of weight control; 14. Dental treatment, as specifically provided in the Schedule of Benefits; h) Fertility agents or sexual enhancement drugs, such as Parlodel, 15. Elective Surgery or Elective Treatment; Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; 16. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects and problems; Refills in excess of the number specified or dispensed after one except when due to a covered Injury or disease process; (1) year of date of the prescription.
17. Flat foot conditions; supportive devices for the foot; subluxations of the 43. Reproductive/Infertility services including but not limited to: family foot; fallen arches; weak feet; chronic foot strain; symptomatic planning; fertility tests; infertility (male or female), including any services complaints of the feet; and routine foot care including the care, cutting or supplies rendered for the purpose or with the intent of inducing and removal of corns, calluses, toenails, and bunions (except capsular conception; premarital examinations; impotence, organic or otherwise; female sterilization procedures; vasectomy; sexual reassignment 18. Genetic medicine or genetic testing, including without limitation surgery; reversal of sterilization procedures; amniocentesis, genetic screening, risk assessment, prevention and/or 44. Research or examinations relating to research studies, or any to determine pre-disposition, genetic counseling, and/or gene therapy; treatment for which the patient or the patient’s representative must 19. Health spa or similar facilities; strengthening programs; sign an informed consent document identifying the treatment in which 20. Hearing examinations; hearing aids; cochlear implants; or other the patient is to participate as a research study or clinical research treatment for hearing defects and problems, except as a result of an infection or trauma. "Hearing defects" means any physical defect of 45. Routine Newborn Infant Care, well-baby nursery and related Physician the ear which does or can impair normal hearing, apart from the 46. Preventive care services; routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in 22. HIV, AIDS Virus, AIDS related Sickness, ARC Syndrome, and AIDS, including any testing for these conditions and any Sickness arising as 47. Services provided normally without charge by the Health Service of 48. Skeletal irregularities of one or both jaws, including orthognathia and 24. Immunizations; preventive medicines or vaccines, except where mandibular retrognathia; temporomandibular joint dysfunction; required for treatment of a covered Injury; deviated nasal septum, including submucous resection and/or other 25. Injury caused by, contributed to, or resulting from, the addiction to or surgical correction thereof; nasal and sinus surgery, except for use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs treatment of a covered Injury or treatment of chronic purulent sinusitis; or medicines that are not taken in the recommended dosage or for the 49. Parachuting, hang gliding, glider flying, parasailing, sail planing, or flight purpose prescribed by the Insured Person's Physician; in any kind of aircraft, except while riding as a passenger on a regularly 26. Injury or Sickness for which benefits are paid or payable under any scheduled flight of a commercial airline; Workers' Compensation or Occupational Disease Law or Act, or 51. Speech therapy; naturopathic services; 27. Injury or Sickness inside the Insured’s home country; 52. Suicide or attempted suicide while sane or insane (including drug 28. Injury or Sickness outside the United States and its possessions, overdose); or intentionally self-inflicted Injury; except when traveling for academic study abroad programs to or from 53. Supplies, except as specifically provided in the policy; 54. Surgical breast reduction, breast augmentation, breast implants or 29. Injury or Sickness when claims payment and/or coverage is prohibited breast prosthetic devices, or gynecomastia 55. Treatment in a Government hospital, unless there is a legal obligation 30. Injury sustained while (a) participating in any intercollegiate, or for the Insured Person to pay for such treatment; professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c) while participatingin any practice or conditioning program for such sport, contest or 57. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded uponrequest for such period not covered); and 58. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat, and treatment of eating disorders such as bulimia and anorexia.
34. Maternity; pregnancy; and Complications of Pregnancy;

Source: http://www.ayusa.org/sites/default/files/UHC%20Flyer%202014.pdf