2008_187_4_brochure_v3.qxp

STUDENT INJURYAND SICKNESSINSURANCE PLANEXCESS I NSU RANCE THIS CERTIFICATE CONTAINS ADEDUCTIBLE PROVISION Table of Contents
Privacy PolicyEligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective And Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Extension Of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Accidental Death And Dismemberment Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Benefits for Outpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Benefits for Procedures Involving Bones or Joints of the Jaw and Facial Region .5Benefits for Postdelivery Care for a Mother and Her Newborn Infant . . . . . . . . . .5Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Benefits for Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Benefits for Mastectomies, Prosthetic Devices and Reconstructive Surgery . . . . . .6Benefits for Post-Surgical Mastectomy Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Benefits for Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Benefits for Child Health Assurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Benefits for Cleft Lip and Cleft Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Benefits For Newborn Infant, Adopted or Foster Child . . . . . . . . . . . . . . . . . . . . . .8Benefits for Hospital Dental Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Exclusions And Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . .13Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality of yournonpublic personal information. We do not disclose any nonpublic personal information about ourcustomers or former customers to anyone, except as permitted or required by law. We believe wemaintain appropriate physical, electronic and procedural safeguards to ensure the security of yournonpublic personal information. You may obtain a detailed copy of our privacy practices bycalling us toll-free at 1-800-767-0700 or by visiting us at www.uhcsr.com.
Eligibility
All registered international students taking credit hours are automatically enrolled in thisinsurance Plan at registration, unless proof of comparable coverage is furnished.
Students must actively attend classes for at least the first 31 days after the date for whichcoverage is purchased. Home study, correspondence, Internet and television (TV) courses donot fulfill the Eligibility requirements that the student actively attend classes. The Companymaintains the right to investigate student status and attendance records to verify that thePolicy Eligibility requirements have been met. If the Company discovers the Eligibilityrequirements have not been met, its only obligation is to refund premium.
Eligible students may also insure their Dependents. Eligible Dependents are the spouse and their children under 25 years of age who are not self-supporting; who live with the Insured or who are full-time or part-time students.
Dependent Eligibility expires concurrently with that of the Insured student.
Effective And Termination Dates
The Master Policy becomes effective August 1, 2008. The individual student’s coveragebecomes effective on the first day of the period for which premium is paid or the date theenrollment form and full premium are received by the Company (or its authorizedrepresentative), whichever is later. The Master Policy terminates July 31, 2009. Coverageterminates on that date or at the end of the period through which premium is paid, whichever isearlier. Dependent coverage will not be effective prior to that of the Insured student or extendbeyond that of the Insured student.
Refunds of premiums are allowed only upon entry into the armed forces.
The Policy is a Non-Renewable One Year Term Policy.
Extension Of Benefits After Termination
The coverage provided under the Policy ceases on the Termination Date. However, if an Insured is Totally Disabled on the Termination Date from a covered Injury or Sickness for which benefits are payable before the Termination Date, Covered Medical Expenses for such Injury or Sickness will continue to be paid as long as the condition continues but not to exceed 12 months after the Termination Date.
However, if an Insured is pregnant on the Termination Date and the conception occurred while covered under this policy, Covered Medical Expenses for such pregnancy will continue to be paid through the term of the pregnancy.
The total payments made in respect of the Insured for such condition both before and after the Termination Date will never exceed the Maximum Benefit. After this “Extension of Benefits” provision has been exhausted, all benefits cease to exist, and under no circumstances will further payments be made.
Pre-Admission Notification
Avidyn should be notified of all Hospital Confinements prior to admission.
PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS:
The patient, Physician or Hospital should telephone 1-877-295-0720 at least five working days prior to the planned admission.
NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient,
patient’s representative, Physician or Hospital should telephone 1-877-295-0720 within two working days of the admission to provide the notification of any admission due to Avidyn is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m., C.S.T.,Monday through Friday. Calls may be left on the Customer Service Department’s voice mailafter hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise
payable under the policy; however, pre-notification is not a guarantee that benefits will be paid.
Schedule of Medical Expense Benefits
Up To $100,000 Maximum Benefit Paid as Specified Below (For Each Injury or Sickness) Inpatient Deductible - $200 (Per Insured Person) (Per Policy Year) Outpatient Deductible - $100 (Per Insured Person) (Per Policy Year) The Outpatient Deductible will be waived when treatment is rendered at the Student Health Center.
The Company will pay 80% up to $25,000 of the Usual & Customary Charges after theDeductible of $200 (Inpatient) or $100 (Outpatient) has been satisfied. After the Companyhas paid $25,000, payment will be increased to 100% of additional Covered MedicalExpenses up to the Maximum Benefit of $100,000 for each Injury or Sickness.
Only one Deductible will apply if more than one insured family member is injured in thesame accident or contracts the same contagious disease within 30 days. Each InsuredPerson will be eligible for the Maximum Benefit. NOTE: No benefits will be paid for services designated as “No Benefits” in the Schedule of Benefits.
Benefits will be paid up to the Maximum Benefit for each service as scheduled below.
Covered Medical Expenses include: INPATIENT
Max = Maximum
U&C = Usual & Customary Charges
Hospital Expense, daily semi-private room rate; and general
nursing care provided by the Hospital. HospitalMiscellaneous Expenses, such as the cost of the operatingroom, laboratory tests, x-ray examinations, anesthesia, drugs(excluding take home drugs) or medicines, therapeuticservices, and supplies. In computing the number of days payableunder this benefit, the date of admission will be counted, butnot the date of discharge.
Intensive Care/Hospital Miscellaneous
Routine Newborn Care, while Hospital Confined; and
routine nursery care provided immediately after birth.
Physiotherapy
Surgeon’s Fees, in accordance with data provided by
Ingenix. If two or more procedures are performed through thesame incision or in immediate succession at the sameoperative session, the maximum amount paid will not exceed 50%of the second procedure and 50% of all subsequent procedures.
(Except Dental Surgery. See: Other) Anesthetist, professional services in connection with
Registered Nurse’s Services, private duty nursing care.
80% of U& C / $12 per hour /90 Days Max Physician’s Visits, benefits are limited to one visit per day
and do not apply when related to surgery.
Pre-Admission Testing, payable within 3 working days
Psychotherapy, benefits are limited to one visit per day.
Psychiatric Hospitals are not covered.
OUTPATIENT
Surgeon’s Fees, in accordance with data provided by Ingenix. 80% of U& C
If two or more procedures are performed through the same
incision or in immediate succession at the same operative
session, the maximum amount paid will not exceed 50% of the
second procedure and 50% of all subsequent procedures.
(Except Dental Surgery. See: Other)
Day Surgery Miscellaneous, excluding non-scheduled 80% of U& C / $1,200 Max
surgery and surgery performed in a Hospital, emergency room,
trauma center, Physician’s Office, or clinic including the cost of the
operating room; laboratory tests and x-ray examinations, including
professional fees; anesthesia; drugs or medicines; and supplies. Usual
and Customary Charges for Day Surgery Miscellaneous are
based on the Outpatient Surgical Facility Charge Index.
Physician’s Visits, benefits are limited to one visit per day 80% of U& C
and do not apply when related to surgery or Physiotherapy.
Anesthetist, professional services administered in 25% of Surgery Allowance
connection with outpatient surgery.
Physiotherapy, benefits are limited to one visit per day. 80% of U& C
See Exclusion 21 for additional limitations.
Medical Emergency, use of the emergency room and 80% of U& C
supplies. Treatment must be rendered within 72 hours
from time of Injury or first onset of Sickness.
Diagnostic X-Rays & Laboratory Services
Radiation Therapy/Chemotherapy
Tests and Procedures, diagnostic services and medical Paid under X-rays & Laboratory
procedures performed by a Physician, other than Physician’s
Visits, Physiotherapy, X-rays and Lab Procedures.
Injections
Prescription Drugs
80% of U& C / $25 Deductible(Per Policy Year) / $150 Max (Per Policy Year) Psychotherapy, including all related or ancillary charges 50% of U& C / $50 per day /
incurred as a result of a Mental & Nervous Disorder (Including $500 Max (Per Policy Year)
Prescription Drugs). Benefits are limited to one visit per day.
OTHER
Ambulance Services
Durable Medical Equipment, a written prescription
must accompany the claim when submitted. Replacement
equipment is not covered.
Consultant Physician Fees, when requested and
approved by the attending Physician.
Dental, made necessary by Injury to Sound, Natural Teeth.
Alcoholism/Drug Abuse
Maternity/Complications of Pregnancy
Elective Abortion
CAT Scan/MRI
Child Health Supervision Services
Maternity Testing
This policy does not cover routine, preventive or screening examinations or testing unless MedicalNecessity is established based on medical records. The following maternity routine tests andscreening exams will be considered, if all other policy provisions have been met. This includes apregnancy test, CBC, Hepatitis B Surface Antigen, Rubella Screen, Syphilis Screen, Chlamydia,HIV, Gonorrhea, Toxoplasmosis, Blood Typing ABO, RH Blood Antibody Screen, Urinalysis, UrineBacterial Culture, Microbial Nucleic Acid Probe, AFP Blood Screening, Pap Smear, and GlucoseChallenge Test (at 24-28 weeks gestation). One Ultrasound will be considered in every pregnancy,without additional diagnosis. Any subsequent ultrasounds can be considered if a claim is submittedwith the Pregnancy Record and Ultrasound report that establishes Medical Necessity. Additionally,the following tests will be considered for women over 35 years of age: Amniocentesis/AFPScreeningand Chromosome Testing. Fetal Stress/Non-Stress tests are payable. Pre-natal vitamins are not covered.
Accidental Death And Dismemberment Benefits
Loss of Life, Limb or Sight
If such Injury shall independently of all other causes and within 180 days from the date ofInjury solely result in any one of the following specific losses, the Insured Person orbeneficiary may request the Company to pay the applicable amount below.
For Loss Of:
Life . . . . . . . . . . . . . . . . . . . . . . . . . . .$10,000Two or More Members . . . . . . . . . . . .$10,000One Member . . . . . . . . . . . . . . . . . . . .$ 5,000Thumb or Index Finger . . . . . . . . . . .$ 2,500 Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or armsand feet or legs, dismemberment by severance at or above the wrist or ankle joint; with regardto eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater) resultingfrom any one Injury will be paid.
Psychotherapy
While Hospital Confined, benefits will be paid for 50% of the Usual and Customary Chargesincurred not to exceed $5,000 maximum Per Policy Year. Benefits for Psychotherapy on an outpatient basis are limited to 50% of the Usual andCustomary Charges incurred up to $50 per day, not to exceed $500 maximum Per Policy Year.
All Covered Medical Expenses incurred as a result of Mental or Nervous Disorder are subjectto the above stated maximums; if otherwise provided under the Policy, this includes itemssuch as Prescription Drugs and diagnostic testing. This benefit is subject to the Deductible.
Psychiatric hospitals are not covered.
Excess Provision
Even if you have other insurance, the Plan may cover unpaid balances and Deductibles, andpay those eligible medical expenses not covered by other insurance.
Benefits will be paid on the unpaid balances after your other insurance has paid. No benefitsare payable for any expense incurred for Injury or Sickness which has been paid or is payableby other valid and collectible insurance or under an automobile insurance policy.
However, this Excess Provision will not be applied to the first $100 of medical expenses incurred.
Covered Medical Expenses excludes amounts not covered by the primary carrier due to penaltiesimposed as a result of the Insured's failure to comply with policy provisions or requirements.
Important: The Excess Provision has no practical application if you do not have other
medical insurance or if your other insurance does not cover the loss.
Mandated Benefits
Benefits will be provided for treatment performed outside a Hospital for any Injury orSickness as defined in the policy provided that such treatment would be covered on aninpatient basis and is provided by a health care provider whose services would be coveredunder the policy if the treatment were performed in a Hospital. Treatment of the Injury orSickness must be a Medical Necessity and must be provided as an alternative to inpatienttreatment in a Hospital. Reimbursement is limited to amounts that are Usual and Customaryfor the treatment or services.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Procedures Involving Bones or Joints of the Jaw and Facial Region Benefits will be paid the same as any other Injury or Sickness for diagnostic or surgicalprocedures involving bones or joints of the jaw and facial region, if, under accepted medicalstandards, such procedure or surgery is medically necessary to treat conditions caused byInjury, Sickness or congenital or developmental deformity.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Postdelivery Care for a Mother and Her Newborn Infant Benefits will be paid the same as any other Sickness for postdelivery care for a mother andher Newborn Infant. Benefits for postdelivery care shall include a postpartum assessment andnewborn assessment and may be provided at the Hospital, at licensed birth centers, at thePhysician's office, at an outpatient maternity center, or in the home by a qualified licensedhealth care professional trained in mother and baby care.
Benefits shall include physical assessment of the newborn and mother, and the performanceof any medically necessary clinical tests and immunizations in keeping with prevailingmedical standards.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits will be provided for all medically appropriate and necessary equipment, supplies,and diabetes outpatient self-management training and educational services used to treatdiabetes, if the patient's treating Physician or a Physician who specializes in the treatment ofdiabetes certifies that such services are necessary. Diabetes outpatient self-managementtraining and educational services must be provided under the direct supervision of a certifieddiabetes educator or a board-certified endocrinologist. Nutrition counseling must be providedby a licensed dietitian.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits will be paid the same as any other Sickness for a mammogram according to thefollowing guidelines: 1. One baseline mammogram for women age thirty-five to thirty-nine, inclusive.
2. A mammogram for women age forty to forty-nine, inclusive, every 2 years or more frequently based on the patient's Physician's recommendation.
3. A mammogram every year for women age fifty and over.
4. One or more mammograms a year upon a Physician's recommendation, for any woman who is at risk for breast cancer because of a personal or family history of breastcancer, because of having a history of biopsy-proven benign breast disease, because ofhaving a mother, sister, or daughter who has or has had breast cancer, or because awoman has not given birth before the age of 30.
5. Benefits are paid, with or without a Physician prescription, if the Insured obtains a mammogram in an office, facility, or health testing service that uses radiologicalequipment registered with the Department of Health and Rehabilitative Services forbreast-cancer screening.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy. Benefits for Mastectomies, Prosthetic Devices and Reconstructive Surgery Benefits will be paid the same as any other Sickness for Mastectomy, prosthetic devices, andReconstructive Surgery incident to the Mastectomy. Breast Reconstructive Surgery must bein a manner chosen by the treating Physician, consistent with prevailing medical standards,and in consultation with the patient. "Mastectomy" means the removal of all or part of the breast for medically necessary reasonsas determined by a licensed Physician, and the term "breast reconstructive surgery" meanssurgery to reestablish symmetry between the two breasts.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Post-Surgical Mastectomy Care Benefits will be paid the same as any other Sickness for outpatient post-surgical follow up carein keeping with prevailing medical standards by a Physician qualified to provide post-surgicalmastectomy care. The treating Physician, after consultation with the Insured, may choose thatthe outpatient care be provided at the most medically appropriate setting, which may includethe Hospital, treating Physician's office, outpatient center, or home of the Insured.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits will be paid the same as any other Sickness for the medically necessary diagnosisand treatment of osteoporosis for high-risk individuals, including, but not limited to, estrogen-deficient individuals who are at clinical risk for osteoporosis, individuals who have vertebralabnormalities, individuals who are receiving long-term glucocorticoid (steroid) therapy,individuals who have primary hyperparathyroidism and individuals who have a familyhistory of osteoporosis.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Child Health Assurance The benefits applicable for children shall include coverage for Child Health SupervisionServices from the moment of birth to 16 years of age.
"Child Health Supervision Services" means Physician-delivered or Physician-supervisedservices which shall include as the minimum benefit coverage for services delivered at theintervals and scope stated below: Child Health Supervision Services shall include periodic visits which shall include a history,a physical examination, a developmental assessment and anticipatory guidance, andappropriate immunizations and laboratory tests. Such services and periodic visits shall beprovided in accordance with prevailing medical standards consistent with theRecommendations for Preventive Pediatric Health Care of the American Academy ofPediatrics. Minimum benefits are limited to one visit payable to one provider for all servicesprovided at each visit.
Benefits shall not be subject to the Deductible, but are subject to all copayment, coinsurance,limitations, or any other provisions of the policy.
Benefits for Cleft Lip and Cleft Palate Benefits will be paid the same as any other Sickness for a child under the age of 18 fortreatment of cleft lip and cleft palate. The benefit will include medical, dental, speech therapy,audiology, and nutrition services if such services are prescribed by the treating Physician andsuch Physician certifies that such services are medically necessary and consequent totreatment of the cleft lip or cleft palate. Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits For Newborn Infant, Adopted or Foster Child Newborn Infant. All health insurance benefits applicable for children will be payable with
respect to a child born to the Named Insured or Dependents after the Effective Date and while
the coverage is in force, from the moment of birth. However, with respect to a Newborn Infant
of a Dependent other than the Insured Person's spouse, the coverage for the Newborn
Infant terminates 18 months after the birth of the Newborn Infant. The coverage for
Newborn Infant consists of coverage for Injury or Sickness including necessary care and
treatment of medically diagnosed congenital defects, birth abnormalities, or prematurity, and
transportation cost of the newborn to and from the nearest available facility appropriately staffed
and equipped to treat the newborn's condition, when such transportation is certified by the
attending Physician as necessary to protect the health and safety of the Newborn Infant. The
coverage of such transportation may not exceed the Usual and Customary Charges, up to $1,000.
The Insured may notify the Company, in writing of the birth of the child not less than 30 daysafter the birth. If timely notice is given, the Company may not charge an additional premiumfor coverage of the Newborn Infant for the duration of the notice period. If timely notice isnot given, the Company may charge the applicable additional premium from the date of birth.
The Company will not deny coverage for a child due to failure to timely notify the Companyof the child.
Adopted or Foster Child. The Named Insured's adopted child or foster child will be covered
to the same extent as other Dependents from the moment of placement in the residence of the
Named Insured. In the case of a newborn adopted child, coverage begins at the moment of
birth and applies as for a newborn infant defined above if a written agreement to adopt such
child has been entered into by the Named Insured prior to the birth of the child whether or
not the agreement is enforceable.
However, coverage will not continue to be provided for an adopted child who is notultimately placed in the Named Insured's residence. The Pre-existing Conditions limitationwill not apply to an adopted child, but will apply to a foster child. The Insured may notify theCompany, in writing, of the adopted or foster child not less than 30 days after placement oradoption. If timely notice is given, the Company may not charge an additional premium forcoverage of such child for the duration of the notice period. If timely notice is not given, theCompany may charge the applicable additional premium from the date of adoption orplacement. The Company will not deny coverage for a child due to failure to timely notifythe Company of such child. Benefits will also be provided for a foster child or other child placed in court-orderedtemporary or other custody of the Insured from the moment of placement.
Benefits for Hospital Dental Procedures Benefits will be paid the same as any other Sickness for general anesthesia and hospitalizationservices for dental treatment or surgery that is considered necessary when the dental conditionis likely to result in a medical condition if left untreated.
The necessary dental care shall be provided to an Insured who: 1. Is under 8 years of age and is determined by a licensed dentist and the child's Physician to require necessary dental treatment in a Hospital or ambulatory surgical center due toa significantly complex dental condition or a developmental disability in which patientmanagement in the dental office has proved to be ineffective; or 2. Has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgeryif not rendered in a Hospital or ambulatory surgical center.
This benefit does not include the diagnosis or treatment of dental disease.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Definitions
INJURY means bodily injury which is: 1) directly and independently caused by specific
accidental contact with another body or object; 2) unrelated to any pathological, functional,
or structural disorder; 3) a source of loss; 4) treated by a Physician within 30 days after the
date of accident; and 5) sustained while the Insured Person is covered under this policy. All
injuries sustained in one accident, including all related conditions and recurrent symptoms of
these injuries will be considered one injury. Injury does not include loss which results wholly
or in part, directly or indirectly, from disease or other bodily infirmity. Covered Medical
Expenses incurred as a result of an injury that occurred prior to this policy's Effective Date
will be considered a Sickness under this policy.
PRE-EXISTING CONDITION means any condition which manifested itself in such a
manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care,
or treatment or for which medical advice, diagnosis, care or treatment was recommended or
received within the 6 months immediately prior to the Insured's Effective Date under this
policy. Routine follow-up care to determine whether a breast cancer has recurred in a person
who has been previously determined to be free of breast cancer does not constitute medical
advice, diagnosis, care, or treatment for purposes of determining pre-existing conditions
unless evidence of breast cancer is found during or as a result of the follow-up care.
SICKNESS means illness or disease of an Insured Person which first manifests itself after
the Effective Date of insurance and while the insurance is in force. All related conditions and
recurrent symptoms of the same or a similar condition will be considered one sickness.
Covered Medical Expenses incurred as a result of an Injury that occurred prior to this policy's
Effective Date will be considered a Sickness under this policy.
USUAL AND CUSTOMARY CHARGES means a reasonable charge which is: 1) usual
and customary when compared with the charges made for similar services and supplies; and
2) made to persons having similar medical conditions in the locality of the Policyholder. No
payment will be made under this policy for any expenses incurred which in the judgment of
the Company are in excess of Usual and Customary Charges.
Exclusions And Limitations
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or supplies for, at, or related to: 1. Acne; acupuncture; allergy, including allergy testing; 2. Addiction such as, nicotine addiction; 8. Congenital conditions, except as specifically provided under Benefits for Newborn or Adopted Infants or Benefits for Cleft Lip and Cleft Palate; 9. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adopted children; removal of warts, non-malignant moles and lesions; 10. Dental treatment, except for accidental Injury to Sound, Natural Teeth; 11. Elective Surgery or Elective Treatment, except cosmetic surgery made necessary as the result of a covered Injury or to correct a disorder of a normal bodily function; 12. Eye examinations, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, except when due to a disease process or except as specifically provided under Benefits for Newborn Infant, Adopted or Foster Child or Benefits for Child Health Assurance; 13. Foot care including: care of corns, bunions (except capsular or bone surgery), calluses; 14. Hearing examinations or hearing aids; or other treatment for hearing defects and problems, except as specifically provided under Benefits for Newborn Infant, Adopted or Foster Child, Benefits for Child Health Assurance and Benefits for Cleft Lip and Cleft Palate. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process; 16. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury; 17. Injury caused by, contributed to, or resulting from the use of alcohol, illegal drugs, or any drugs or medicines that are not taken in the recommended dosage or for the purpose prescribed by the Insured Person's Physician; 18. Injury or Sickness for which benefits are paid under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 19. Injury sustained while (a) participating in any interscholastic, club, intercollegiate, or professional sport, contest or competition; (b) traveling to or from such sport, contestor competition as a participant; or (c) while participating in any practice orconditioning program for such sport, contest or competition; 20. Experimental organ transplants; if not experimental in nature, organ transplants will be covered as any other Sickness; organ donation; 21. Outpatient Physiotherapy; except for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2) withinthe 30 days immediately following the attending Physician's release for rehabilitation; orwhen referred by the Student Health Center; 22. Participation in a riot or civil disorder; commission of or attempt to commit a felony; 23. Pre-existing Conditions will apply for the first 6 months, except for individuals who have been continuously insured under the school's student insurance policy for at least12 consecutive months. Credit will be given for the time the Insured was coveredunder a previous similar plan if the previous coverage was continuous to a date notmore than 63 days prior to the Insured’s Effective Date under this policy; 24. Prescription Drugs, services or supplies as follows, except as specifically provided a. Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use; b. Birth control and/or contraceptives, oral or other, whether medication or c. Immunization agents, biological sera, blood or blood products administered d. Drugs labeled, “Caution - limited by federal law to investigational use” or e. Products used for cosmetic purposes;f. Drugs used to treat or cure baldness; anabolic steroids used for body building;g. Anorectics - drugs used for the purpose of weight control;h. Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; i. Growth hormones; orj. Refills in excess of the number specified or dispensed after one (1) year of 25. Reproductive/infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for thepurpose or with the intent of inducing conception; premarital examinations; impotence,organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversalof sterilization procedures; 26. Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery; except asspecifically provided under Benefits for Newborn Infant, Adopted or Foster Child orBenefits for Child Health Assurance; 27. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specificallyprovided in the policy; except as specifically provided under Benefits for Child HealthAssurance; 28. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 29. Deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery, except for treatment of chronic purulentsinusitis; 30. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on aregularly scheduled flight of a commercial airline; 32. Suicide or attempted suicide while sane or insane (including drug overdose); or 33. Supplies, except as specifically provided in the policy; 34. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; 35. Treatment in a Government hospital, unless there is a legal obligation for the Insured 36. 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 upon request for such period notcovered); and 37. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat.
Scholastic Emergency Services:
Global Emergency Medical Assistance
If you are an international student studying in the United States or a spouse or minor child ofan international student studying in the United States and are covered by this insurance plan,you are eligible for Scholastic Emergency Services (SES) while outside of your homecountry. The Emergency Medical Evacuation and Return of Mortal Remains servicesprovided by SES meet U.S. visa requirements. The Emergency Medical Evacuation servicesare not meant to be used in lieu of or replace or local emergency services such as anambulance requested through emergency 911 telephone assistance. All SES services must bearranged and provided by SES. Key Services include:
Medical Consultation, Evaluation and Referrals Care for Minor Children Left Unattended Due to a Medical Incident Please visit your school’s insurance coverage page at www.uhcsr.com for the SES GlobalEmergency Assistance Services brochure which includes service descriptions and programexclusions and limitations.
(877) 488-9833 Toll-free within the United States (609) 452-8570 Collect outside the United States Services are also accessible via e-mail at [email protected].
When calling the SES Operations Center, please be prepared to provide: 1. Caller's name, telephone and (if possible) fax number, and relationship to the patient2. Patient's name, age, sex, and Reference Number3. Description of the patient’s condition4. Name, location, and telephone number of hospital, if applicable5. Name and telephone number of the attending physician6. Information of where the physician can be immediately reached SES is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan andare subject to the policy limits of your health coverage. All assistance services must bearranged and provided by SES. Claims for reimbursement for services not provided by SESwill not be accepted. Please refer to your SES brochure for Program Guidelines as well aslimitations and exclusions pertaining to the SES program.
Claim Procedure
In the event of Injury or Sickness, students should: 1. Report to the Student Health Service or Infirmary for treatment or referral, or when not in school, to their Physician or Hospital.
2. Mail to the address below all medical and hospital bills along with the patient’s name and insured student’s name, address, Social Security number and name of theCollege under which the student is insured. A Company claim form is not required forfiling a claim.
3. File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 90 days of service. Bills submitted after one year willnot be considered for payment except in the absence of legal capacity.
The plan is Underwritten by:
United HealthCare Insurance Company
UnitedHealthcare StudentResources
ONLINE SERVICES: Please visit our Website at www.uhcsr.com for brochures, enrollmentcards (printable using Adobe Acrobat), Coverage Receipts, ID cards, claims status and otherservices.
Policyholder Service:
Please keep this Certificate as a general summary of the insurance. The Master Policy on fileat the College contains all of the provisions, limitations, exclusions and qualifications of yourinsurance benefits, some of which may not be included in this Certificate. The Master Policyis the contract and will govern and control the payment of benefits.
This Certificate is based on Policy # 2008-187-4

Source: http://fscmocs.athleticsite.net/pdf/International2008.pdf