2011-200422-91-1 brochure_layout

STUDENT INJURY ANDSICKNESS INSURANCE PLAN This Certificate Contains aDeductible Provision This Plan is Underwritten byUnitedHealthcare InsuranceCompany TOLL-FREE NUMBER FOR INQUIRIES: For inquiriesand to obtain information about your coverage, or forassistance in resolving a complaint, please call1-800-505-4160.
Table of Contents
Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . .1Extension of Benefits after Termination . . . . . . . . .2Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . .3Schedule of Medical Expense Benefits Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Sickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Accidental Death and Dismemberment . . . . . . . . .11Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Outpatient Services . . . . . . . . . . .12Benefits for Procedures Involving Bones or Benefits for Hospital Dental Procedures . .13Benefits for Cleft Lip and Cleft Palate . . . . .13Benefits for Osteoporosis . . . . . . . . . . . . . . . . .13Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . .14Benefits for Newborn Infant, Adopted or Foster Child . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Benefits for Postdelivery Care for a Mother and Her Newborn Infant . . . . . . . . . . . . . .15 Benefits for Mammography . . . . . . . . . . . . . . .15Benefits for Mastectomies, Prosthetic Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Benefits for Child Health Assurance . . . . . .17 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . .19Collegiate Assistance Program . . . . . . . . . . . . . . . . .21Scholastic Emergency Services: Global Emergency Medical Assistance . . . .22 Claim Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Privacy Policy
We know that your privacy is important to you and westrive to protect the confidentiality of your non-publicpersonal information. We do not disclose any non-public personal information about our customers orformer customers to anyone, except as permitted orrequired by law. We believe we maintain appropriatephysical, electronic and procedural safeguards toensure the security of your non-public personalinformation. You may obtain a copy of our privacypractices by calling us toll-free at 1- 800-505-4160.
Eligibility
All students taking 6 or more credit hours are eligibleto enroll in the Injury Only Benefits or the Injury andSickness Benefits of this insurance Plan.
Students must actively attend classes for at least thefirst 31 days after the date for which coverage ispurchased. Home study, correspondence, Internet andtelevision (TV) courses do not fulfill the Eligibilityrequirements that the student actively attend classes.
The Company maintains its right to investigate studentstatus and attendance records to verify that the PolicyEligibility requirements have been met. If the Companydiscovers the Eligibility requirements have not beenmet, its only obligation is to refund premium.
Eligible students who do enroll may also insure theirDependents. Eligible Dependents are the spouse andtheir children under 25 years of age who are not self-supporting; who live with the Insured or who are a full-time or part-time student. The named Insured mayalso cover a dependent child to the end of the year inwhich the Dependent reaches age 30 under certaincircumstances.
Dependent Eligibility expires concurrently with that ofthe Insured student.
Effective and Termination Dates
The Master Policy becomes effective at 12:01 a.m.,August 27, 2011. Coverage becomes effective on thefirst day of the period for which premium is paid or thedate the enrollment form and full premium arereceived by the Company (or its authorizedrepresentative), whichever is later. The Master Policyterminates at 11:59 p.m., August 26, 2012. Coverageterminates on that date or at the end of the periodthrough which premium is paid, whichever is earlier.
Dependent coverage will not be effective prior to thatof the Insured student or extend beyond that of theInsured student.
If paying premiums by any payment period other thanannual, coverage expires as follows: You must meet the Eligibility requirements each time
you pay a premium to continue insurance coverage. To
avoid a lapse in coverage, your premium must be
received within 14 days after the coverage expiration
date. It is the student's responsibility to make timely
renewal payments to avoid a lapse in coverage.
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 this Policy ceases on theTermination Date. However, if an Insured is TotallyDisabled on the Termination Date from a covered Injuryor Sickness for which benefits are payable before theTermination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long asthe condition continues but not to exceed 12 monthsafter the termination date.
However, if an Insured is pregnant on the TerminationDate and the conception occurred while coveredunder this policy, Covered Medical Expenses for suchpregnancy will continue to be paid through the term ofthe pregnancy.
The total payments made in respect of the Insured forsuch condition both before and after the TerminationDate will never exceed the Maximum Benefit.
After this "Extension of Benefits" provision has beenexhausted, all benefits cease to exist, and under nocircumstances will further payments be made.
Pre-Admission Notification
UMR Care Management should be notified of allHospital Confinements prior to admission.
EMERGENCY HOSPITALIZATIONS: The patient,Physician or Hospital should telephone 1-877-295-0720 at least five working days prior to theplanned admission.
representative, Physician or Hospital shouldtelephone 1-877-295-0720 within two workingdays of the admission to provide notification ofany admission due to Medical Emergency.
UMR Care Management is open for Pre-AdmissionNotification calls from 8:00 a.m. to 6:00 p.m. C.S.T.,Monday through Friday. Calls may be left on theCustomer Service Department's voice mail after hoursby calling 1-877-295-0720.
IMPORTANT: Failure to follow the notificationprocedures will not affect benefits otherwise payableunder the policy; however, pre-notification is not aguarantee that benefits will be paid.
Schedule of Medical Expense Benefits
Up To $50,000 Maximum Benefit Paid as Specified The Policy provides benefits for the Usual &Customary Charges, incurred by an Insured Personfor loss due to a covered Injury up to the MaximumBenefit of $50,000 for each Injury. Benefits will bepaid up to the Maximum Benefit for each service asscheduled below.
NOTE: No benefits will be paid for servicesdesignated “No Benefits” in the Schedule. CoveredMedical Expenses include: INPATIENT
room rate; general nursing careprovided by the Hospital. HospitalMiscellaneous Expenses, such as thecost of the operating room, laboratorytests, x-ray examinations, anesthesia,drugs (excluding take home drugs) ormedicines, therapeutic services, andsupplies. In computing the number ofdays payable under this benefit, thedate of admission will be counted, butnot the date of discharge.
data provided by FAIR Health, Inc. Iftwo or more procedures areperformed through the same incisionor in immediate succession at thesame operative session, the maximumamount paid will not exceed 50% ofthe second procedure and 50% of allsubsequent procedures. (Except Dental Surgery. See Other) administered in connection withinpatient surgery.
INPATIENT
Physician’s Visits, benefits are limited to one visit per day and do not applywhen related to surgery.
OUTPATIENT
data provided by FAIR Health, Inc. Iftwo or more procedures are performedthrough the same incision or inimmediate succession at the sameoperative session, the maximumamount paid will not exceed 50% ofthe second procedure and 50% of allsubsequent procedures.
(Except Dental Surgery. See Other) scheduled surgery performed in aHospital, including the cost of theoperating room; laboratory tests and x-rayexaminations, including professional fees;anesthesia; drugs or medicines; andsupplies. Usual and Customary Chargesfor Day Surgery Miscellaneous are basedon the Outpatient Surgical Facility ChargeIndex.
administered in connection withoutpatient surgery.
Physician’s Visits, benefits are limited to one visit per day. Benefits forPhysician’s Visits do not apply whenrelated to surgery or Physiotherapy.
one visit per day. (Review of MedicalNecessity will be performed agter 12visits per Injury) Diagnostic X-Rays & Laboratory Services OUTPATIENT
Treatment must be rendered within 72hours from time of Injury.
prescription must accompany the claimwhen submitted. Replacementequipment is not covered.
requested and approved by theattending Physician.
Injury to Sound, Natural Teeth only.
Schedule of Medical Expense Benefits -
SICKNESS
Up To $50,000 Maximum Benefit Paid as Specified The Policy provides benefits for the Usual &Customary Charges, incurred by an Insured Personfor loss due to a covered Sickness up to theMaximum Benefit of $50,000 for each Sickness.
Benefits will be paid up to the Maximum Benefit foreach service as scheduled below. NOTE: No benefits will be paid for servicesdesignated “No Benefits” in the Schedule. CoveredMedical Expenses include: INPATIENT
SICKNESS
private room rate; general nursing careprovided by the Hospital.
anesthesia, drugs (excluding takehome drugs) or medicines, therapeuticservices, and supplies. In computingthe number of days payable under thisbenefit, the date of admission will becounted, but not the date of discharge. INPATIENT
SICKNESS
through the same incision or inimmediate succession at the sameoperative session, the maximumamount paid will not exceed 50% ofthe second procedure and 50% of allsubsequent procedures.
(Except Dental Surgery. See Other) Physician’s Visits, benefits are limited ($1,000 Aggregate maximum for bothInpatient and Outpatient) OUTPATIENT
SICKNESS
two or more procedures areperformed through the same incisionor in immediate succession at thesame operative session, themaximum amount paid will notexceed 50% of the secondprocedure and 50% of allsubsequent procedures.
(Except Dental Surgery. See Other) Hospital, including the cost of theoperating room; laboratory tests andx-ray examinations, includingprofessional fees; anesthesia; drugsor medicines; and supplies. Usual andCustomary Charges for Day SurgeryMiscellaneous are based on theOutpatient Surgical Facility ChargeIndex.
Physician’s Visits, benefits are limited related to surgery or Physiotherapy.
Treatment must be rendered within72 hours from first onset of Sickness.
OUTPATIENT
SICKNESS
Benefits are limited to one visit perday.
($1,000 Aggregate maximum forboth Inpatient and Outpatient) claim when submitted. Replacementequipment is not covered.
Maternity Testing
This policy does not cover routine, preventive orscreening examinations or testing unless MedicalNecessity is established based on medical records. Thefollowing maternity routine tests and screening examswill be considered if all other policy provisions have beenmet: Initial screening at first visit – Pregnancy test:Urine human chorionic gonatropin (HCG),Asymptomatic bacteriuria: Urine culture, Blood type andRh antibody, Rubella, Pregnancy-associated plasmaprotein-A (PAPPA) (first trimester only), Free betahuman chorionic gonadotrophin (hCG) (first trimesteronly), Hepatitis B: HBsAg, Pap smear, Gonorrhea: Gcculture, Chlamydia: chlamydia culture, Syphilis: RPR,HIV: HIV-ab; and Coombs test; Each visit – Urineanalysis; Once every trimester – Hematocrit andHemoglobin; Once during first trimester – Ultrasound;Once during second trimester – Ultrasound (anatomyscan); Triple Alpha-fetoprotein (AFP), Estriol, hCG orQuad screen test Alpha-fetoprotein (AFP), Estriol, hCG,inhibin-a; Once during second trimester if age 35 or over- Amniocentesis or Chorionic villus sampling (CVS);Once during second or third trimester – 50g Glucola(blood glucose 1 hour postprandial); and Once duringthird trimester - Group B Strep Culture. Pre-natalvitamins are not covered. For additional informationregarding Maternity Testing, please call the Company at1-800-505-4160.
Accidental Death and Dismemberment
Loss of Life, Limb or SightIf such Injury shall independently of all other causesand within 180 days from the date of Injury solely resultin any one of the following specific losses, the InsuredPerson or beneficiary may request the Company to paythe applicable amount below.
For Loss Of: Member means hand, arm, foot, leg, or eye. Loss shallmean with regard to hands or arms and feet or legs,dismemberment by severance at or above the wrist orankle joint; with regard to eyes, entire and irrecoverableloss of sight. Only one specific loss (the greater)resulting from any one Injury will be paid.
Excess Provision
Even if you have other insurance, the Plan may coverunpaid balances, Deductibles and pay those eligiblemedical expenses not covered by other insurance.
Benefits will be paid on the unpaid balances after yourother insurance has paid. No benefits are payable forany expense incurred for Injury or Sickness which hasbeen paid or is payable by other valid and collectibleinsurance.
However, this Excess Provision will not be applied tothe first $100 of medical expenses incurred.
Covered Medical Expenses excludes amounts notcovered by the primary carrier due to penaltiesimposed as a result of the Insured's failure to complywith policy provisions or requirements.
Important: The Excess Provision has no practicalapplication if you do not have other medical insuranceor if your other insurance does not cover the loss.
Mandated Benefits
Benefits for Outpatient Services
Benefits will be provided for treatment performedoutside a Hospital for any Injury or Sickness as definedin the policy provided that such treatment would becovered on an inpatient basis and is provided by ahealth care provider whose services would be coveredunder the policy if the treatment were performed in aHospital. Treatment of the Injury or Sickness must be aMedical Necessity and must be provided as analternative to inpatient treatment in a Hospital.
Reimbursement is limited to amounts that are Usualand Customary for the treatment or services.
Benefits shall be subject to all Deductible, copayment,coinsurance, limitations, or any other provisions of thepolicy.
Benefits for Procedures Involving Bones or
Joints of The Jaw and Facial Region
Benefits will be paid the same as any other Injury orSickness for diagnostic or surgical proceduresinvolving bones or joints of the jaw and facial region, if,under accepted medical standards, such procedure orsurgery is medically necessary to treat conditionscaused by Injury, Sickness or congenital ordevelopmental deformity.
Benefits shall be subject to all Deductible, copayment,coinsurance, limitations, or any other provisions of thepolicy.
Benefits for Hospital Dental Procedures
Benefits will be paid the same as any other Sicknessfor general anesthesia and hospitalization services fordental treatment or surgery that is considerednecessary when the dental condition is likely to resultin a medical condition if left untreated. The necessarydental 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 torequire necessary dental treatment in a Hospitalor ambulatory surgical center due to a significantlycomplex dental condition or a developmentaldisability in which patient management in thedental office has proved to be ineffective; or 2. Has one or more medical conditions that would create significant or undue medical risk for theindividual in the course of delivery of anynecessary dental treatment or surgery if notrendered in a Hospital or ambulatory surgicalcenter.
This benefit does not include the diagnosis ortreatment of dental disease.
Benefits shall be subject to all Deductible, copayment,coinsurance, limitations, or any other provisions of thepolicy.
Benefits for Cleft Lip and Cleft Palate
Benefits will be paid the same as any other Sicknessfor a child under the age of 18 for treatment of cleft lipand cleft palate. The benefit will include medical,dental, speech therapy, audiology, and nutritionservices if such services are prescribed by the treatingPhysician and such Physician certifies that suchservices 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 other provisions of thepolicy.
Benefits for Osteoporosis
Benefits will be paid the same as any other Sicknessfor the medically necessary diagnosis and treatmentof osteoporosis for high-risk individuals, including, butnot limited to, estrogen-deficient individuals who areat clinical risk for osteoporosis, individuals who havevertebral abnormalities, individuals who are receivinglong-term glucocorticoid (steroid) therapy, individualswho have primary hyperparathyroidism and individualswho have a family history of osteoporosis.
Benefits shall be subject to all Deductible, copayment,coinsurance, limitations, or any other provisions of thepolicy.
Benefits for Diabetes
Benefits will be provided for all medically appropriateand necessary equipment, supplies, and diabetesoutpatient self-management training and educationalservices used to treat diabetes, if the patient's treatingPhysician or a Physician who specializes in thetreatment of diabetes certifies that such services arenecessary. Diabetes outpatient self-managementtraining and educational services must be providedunder the direct supervision of a certified diabeteseducator or a board-certified endocrinologist. Nutritioncounseling must be provided by a licensed dietitian.
Benefits shall be subject to all Deductible, copayment,coinsurance, limitations, or any other provisions of thepolicy.
Benefits for Newborn Infant, Adopted
or Foster Child
Newborn Infant. All health insurance benefitsapplicable for children will be payable with respect to achild born to the Named Insured or Dependents afterthe Effective Date and while the coverage is in force,from the moment of birth. However, with respect to aNewborn Infant of a Dependent other than the InsuredPerson's spouse, the coverage for the Newborn Infantterminates 18 months after the birth of the NewbornInfant.
The coverage for Newborn Infant consists of coveragefor Injury or Sickness including necessary care andtreatment of medically diagnosed congenital defects,birth abnormalities, or prematurity, and transportationcost of the newborn to and from the nearest availablefacility appropriately staffed and equipped to treat thenewborn's condition, when such transportation iscertified by the attending Physician as necessary toprotect the health and safety of the Newborn Infant.
The coverage of such transportation may not exceedthe Usual and Customary Charges, up to $1,000.
The Insured may notify the Company, in writing of thebirth of the child not less than 30 days after the birth.
If timely notice is given, the Company may not chargean additional premium for coverage of the NewbornInfant for the duration of the notice period. If timelynotice is not given, the Company may charge theapplicable additional premium from the date of birth.
The Company will not deny coverage for a child due tofailure to timely notify the Company of the child.
Adopted or Foster Child. The Named Insured'sadopted child or foster child will be covered to thesame extent as other Dependents from the moment ofplacement in the residence of the Named Insured. Inthe case of a newborn adopted child, coverage beginsat the moment of birth and applies as for a newborninfant defined above if a written agreement to adoptsuch child has been entered into by the NamedInsured prior to the birth of the child whether or not theagreement is enforceable.
However, coverage will not continue to be provided foran adopted child who is not ultimately placed in theNamed Insured's residence. The Pre-existingConditions limitation will not apply to an adopted child,but will apply to a foster child. The Insured may notifythe Company, in writing, of the adopted or foster childnot less than 30 days after placement or adoption. Iftimely notice is given, the Company may not charge anadditional premium for coverage of such child for theduration of the notice period. If timely notice is notgiven, the Company may charge the applicableadditional premium from the date of adoption orplacement. The Company will not deny coverage for achild due to failure to timely notify the Company ofsuch child.
Benefits will also be provided for a foster child or otherchild placed in court-ordered temporary or othercustody of the Insured from the moment of placement.
Benefits for Postdelivery Care for a Mother
and Her Newborn Infant
Benefits will be paid the same as any other Sicknessfor postdelivery care for a mother and her NewbornInfant. Benefits for postdelivery care shall include apostpartum assessment and newborn assessmentand may be provided at the Hospital, at licensed birthcenters, at the Physician's office, at an outpatientmaternity center, or in the home by a qualified licensedhealth care professional trained in mother and babycare. Benefits shall include physical assessment of thenewborn and mother, and the performance of anymedically necessary clinical tests and immunizations inkeeping with prevailing medical standards.
Benefits shall be subject to all Deductible, copayment,coinsurance, limitations, or any other provisions of thepolicy.
Benefits for Mammography
Benefits will be paid the same as any other Sicknessfor a mammogram according to the followingguidelines: 1. One baseline mammogram for women age thirty- 2. A mammogram for women age forty to forty-nine, inclusive, every 2 years or more frequently basedon the patient's Physician's recommendation.
3. A mammogram every year for women age fifty and Physician's recommendation, for any woman whois at risk for breast cancer because of a personalor family history of breast cancer, because ofhaving a history of biopsy-proven benign breastdisease, because of having a mother, sister, ordaughter who has or has had breast cancer, orbecause a woman has not given birth before theage of 30.
5. Benefits are paid, with or without a Physician prescription, if the Insured obtains a mammogramin an office, facility, or health testing service thatuses radiological equipment registered with theDepartment of Health and Rehabilitative Servicesfor breast-cancer screening.
Benefits shall be subject to all Deductible, copayment,coinsurance, limitations, or any other provisions of thepolicy.
Benefits for Mastectomies, Prosthetic Devices
and Reconstructive Surgery
Benefits will be paid the same as any other Sicknessfor Mastectomy, prosthetic devices, andReconstructive Surgery incident to the Mastectomy.
Breast Reconstructive Surgery must be in a mannerchosen by the treating Physician, consistent withprevailing medical standards, and in consultation withthe patient.
"Mastectomy" means the removal of all or part of thebreast for medically necessary reasons as determinedby a licensed Physician, and the term "breastreconstructive surgery” means surgery to reestablishsymmetry between the two breasts.
Benefits shall be subject to all Deductible, copayment,coinsurance, limitations, or any other provisions of thepolicy.
Benefits for Post-Surgical Mastectomy Care
Benefits will be paid the same as any other Sicknessfor outpatient postsurgical follow-up care in keepingwith prevailing medical standards by a Physicianqualified to provide postsurgical mastectomy care. Thetreating Physician, after consultation with the Insured,may choose that the outpatient care be provided at themost medically appropriate setting, which may includethe Hospital, treating Physician's office, outpatientcenter, or home of the Insured.
Benefits shall be subject to all Deductible, copayment,coinsurance, limitations, or any other provisions of thepolicy.
Benefits for Child Health Assurance
The benefits applicable for Dependent children shallinclude coverage for Child Health SupervisionServices from the moment of birth to 16 years of age.
"Child Health Supervision Services" means Physician-delivered or Physician-supervised services which shallinclude as the minimum benefit coverage for servicesdelivered at the intervals and scope stated below:Child Health Supervision Services shall includeperiodic visits which shall include a history, a physicalexamination, a developmental assessment andanticipatory guidance, and appropriate immunizationsand laboratory tests. Such services and periodic visitsshall be provided in accordance with prevailingmedical standards consistent with theRecommendations for Preventive Pediatric HealthCare of the American Academy of Pediatrics.
Minimum benefits are limited to one visit payable toone provider for all services provided at each visit.
Benefits shall not be subject to the Deductible, but aresubject to all copayment, coinsurance, limitations, orany other provisions of the policy.
Definitions
COVERED MEDICAL EXPENSES means reasonablecharges which are: 1) not in excess of Usual andCustomary Charges; 2) not in excess of the maximumbenefit amount payable per service as specified in theSchedule of Benefits; 3) made for services andsupplies not excluded under the policy; 4) made forservices and supplies which are a Medical Necessity;5) made for services included in the Schedule ofBenefits; and 6) in excess of the amount stated as aDeductible, if any.
Covered Medical Expenses will be deemed “incurred”only: 1) when the covered services are provided; and2) when a charge is made to the Insured Person forsuch services.
INJURY means bodily injury which is: 1) directly andindependently caused by specific accidental contactwith another body or object; 2) unrelated to anypathological, functional, or structural disorder; 3) asource of loss; 4) treated by a Physician within 30days after the date of accident; and 5) sustained while the Insured Person is covered underthis policy. All injuries sustained in one accident,including all related conditions and recurrentsymptoms of these injuries will be considered oneinjury. Injury does not include loss which results whollyor in part, directly or indirectly, from disease or otherbodily infirmity. Covered Medical Expenses incurred asa result of an injury that occurred prior to this policy'sEffective Date will be considered a Sickness under thispolicy.
PRE-EXISTING CONDITION means any conditionwhich manifested itself in such a manner as wouldcause an ordinarily prudent person to seek medicaladvice, diagnosis, care, or treatment or for whichmedical advice, diagnosis, care or treatment wasrecommended or received within the 6 monthsimmediately prior to the Insured's Effective Date underthis policy. Routine follow-up care to determinewhether a breast cancer has recurred in a person whohas been previously determined to be free of breastcancer does not constitute medical advice, diagnosis,care, or treatment for purposes of determining pre-existing conditions unless evidence of breast cancer isfound during or as a result of the follow-up care.
SICKNESS means illness or disease of an InsuredPerson which first manifests itself after the EffectiveDate of insurance and while the insurance is in force.
All related conditions and recurrent symptoms of thesame or a similar condition will be considered onesickness. Covered Medical Expenses incurred as aresult of an Injury that occurred prior to this policy'sEffective Date will be considered a sickness under thispolicy.
TOTALLY DISABLED means a condition of a NamedInsured which, because of Sickness or Injury, rendersthe Insured unable to actively attend classes. A TotallyDisabled Dependent is one who is unable to performall activities usual for a person of that age.
USUAL AND CUSTOMARY CHARGES means areasonable charge which is: 1) usual and customarywhen compared with the charges made for similarservices and supplies; and 2) made to persons havingsimilar medical conditions in the locality of thePolicyholder. No payment will be made under thispolicy for any expenses incurred which in the judgmentof the Company are in excess of Usual and CustomaryCharges.
Exclusions and Limitations
No benefits will be paid for: a) loss or expense causedby, contributed to, or resulting from; or b) treatment,services or supplies for, at, or related to: 1. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits areotherwise payable under this policy or for newbornor adopted children; 2. Dental treatment, except for accidental Injury to 3. Elective Surgery or Elective Treatment, except cosmetic surgery made necessary as the result ofa covered Injury or to correct a disorder of anormal bodily function; 4. Elective abortion;5. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting ofeyeglasses or contact lenses, vision correctionsurgery, or other treatment for visual defects andproblems; except when due to a disease process;except as specifically provided under Benefits forNewborn Infant, Adopted or Foster Child orBenefits for Child Health Assurance; 6. Hearing examinations or hearing aids; or other treatment for hearing defects and problems,except as specifically provided under Benefits forNewborn Infant, Adopted or Foster Child, Benefitsfor Child Health Assurance and Benefits for CleftLip and Cleft Palate. "Hearing defects" means anyphysical defect of the ear which does or canimpair normal hearing, apart from the diseaseprocess; 7. Hirsutism; alopecia;8. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines;except where required for treatment of a coveredInjury; 9. Injury or Sickness for which benefits are paid under any Workers' Compensation orOccupational Disease Law or Act, or similarlegislation; 10. Injury sustained while (a) participating in any interscholastic, club, intercollegiate, orprofessional sport, contest or competition; (b)traveling to or from such sport, contest orcompetition as a participant; or (c) whileparticipating in any practice or conditioningprogram for such sport, contest or competition; 11. Investigational services;12. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting;except in self-defense; 13. Pre-existing Conditions, will apply for the first 6 months, except for individuals who have beencontinuously insured under the school's studentinsurance policy for at least 12 consecutivemonths. Credit will be given for the time theInsured was covered under a previous similarplan if the previous coverage was continuous toa date not more than 63 days prior to theInsured's Effective Date under this policy; 14. Prescription Drugs, services or supplies as follows, except as specifically provided in thepolicy; Therapeutic devices or appliances,including: hypodermic needles, syringes,support garments and other non-medicalsubstances, regardless of intended use; 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 administered on anoutpatient basis; d. Drugs labeled, "Caution - limited by federal law to investigational use" or experimentaldrugs; 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 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 date of theprescription; 15. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility(male or female), including any services orsupplies rendered for the purpose or with theintent of inducing conception; premaritalexaminations; impotence, organic or otherwise;tubal ligation; vasectomy; sexual reassignmentsurgery; reversal of sterilization procedures; 16. Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48hours for vaginal delivery or 96 hours forcesarean delivery; except as specifically providedunder Benefits for Newborn Infant, Adopted orFoster Child or Benefits for Child HealthAssurance; 17. Routine physical examinations and routine testing; preventive testing or treatment; screeningexams or testing in the absence of Injury orSickness; except as specifically provided inthepolicy; or except as specifically provided underBenefits for Child Health Assurance; 18. Services provided normally without charge by the Health Service of the Policyholder; or servicescovered or provided by the student health fee; 19. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flightin any kind of aircraft, except while riding as apassenger on a regularly scheduled flight of acommercial airline; 20. Suicide or attempted suicide while sane or insane (including drug overdose); or intentionallyself-inflicted Injury; 21. Supplies, except as specifically provided in the 22. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, orgynecomastia; except as specifically provided inthe policy; 23. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to payfor such treatment; 24. 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 forsuch period not covered); and 25. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery forremoval of excess skin or fat, and treatment ofeating disorders such as bulimia and anorexia,Exception: benefits will be provided for thetreatment of dehydration and electrolyteimbalance associated with eating disorders.
Collegiate Assistance Program
Insured Students have access to nurse advice, healthinformation, and counseling support 24 hours a day, 7days a week by dialing the number indicated on thepermanent ID card. Collegiate Assistance Program isstaffed by Registered Nurses and Licensed Clinicianswho can help students determine if they need to seekmedical care, need legal/financial advice or may needto talk to someone about everyday issues that can beoverwhelming. Scholastic Emergency Services:
Global Emergency Medical Assistance
If you are a student insured with this insurance plan,you and your insured spouse and minor child(ren) areeligible for Scholastic Emergency Services (SES). Therequirements to receive these services are as follows:International Students, insured spouse and insuredminor child(ren): You are eligible to receive SESworldwide, except in your home country.
Domestic Students, insured spouse and insured minorchild(ren): You are eligible for SES when 100 miles ormore away from your campus address and 100 milesor more away from your permanent home address orwhile participating in a Study Abroad program. SES includes Emergency Medical Evacuation andReturn of Mortal Remains that meet the US StateDepartment requirements. The Emergency MedicalEvacuation services are not meant to be used in lieuof or replace local emergency services such as anambulance requested through emergency 911telephone assistance. All SES services must bearranged and provided by SES, Inc., any services notarranged by SES, Inc. will not be considered forpayment. Key Services include: * Medical Consultation, Evaluation and Referrals* Prescription Assistance* Foreign Hospital Admission Guarantee* Critical Care Monitoring* Emergency Medical Evacuation* Return of Mortal Remains* Medically Supervised Repatriation* Transportation to Join Patient* Emergency Counseling Services* Interpreter and Legal Referrals* Lost Luggage or Document Assistance* Care for Minor Children Left Unattended Please visit your school's insurance coverage page atwww.firststudent.com for the SES Global EmergencyAssistance Services brochure which includes servicedescriptions and program exclusions and limitations.
To access services please call:(877) 488-9833 Toll-free within the United States(609) 452-8570 Collect outside the United States Services are also accessible via e-mail [email protected].
When calling the SES Operations Center, please beprepared to provide: 1. Caller's name, telephone and (if possible) fax 2. Patient's name, age, sex, and Reference 3. Description of the patient's condition;4. Name, location, and telephone number of 5. Name and telephone number of the attending 6. Information of where the physician can be SES is not travel or medical insurance but a serviceprovider for emergency medical assistance services.
All medical costs incurred should be submitted to yourhealth plan and are subject to the policy limits of yourhealth coverage. All assistance services must bearranged and provided by SES, Inc. Claims forreimbursement of services not provided by SES will notbe accepted. Please refer to your SES brochure forProgram Guide at www.firststudent.com for additionalinformation, including limitations and exclusionspertaining to the SES program.
Claim Procedures
In the event of Injury or Sickness, students should: 1) Report to their Physician or Hospital.
2) Mail to the address below all medical and hospital bills along with the patient's name and insuredstudent's name, address, social security numberand name of the university under which thestudent is insured. A Company claim form is notrequired for filing a claim.
3) File claim within 30 days of Injury or first treatment for a Sickness. Bills should be receivedby the Company within 90 days of service. Billssubmitted after one year will not be considered forpayment except in the absence of legal capacity.
The Plan is Underwritten by
Direct all Claims and/or
Customer Services Inquires to:
First Student
P.O. Box 809025
Dallas, Texas 75380-9025
1-800-505-4160
or visit our website at www.firststudent.com
Servicing Agent:
Health Benefits Concepts, Inc.
Albert C. Belanger
P. O. Box 15408
Surfside, SC 29587
Phone 1-800-463-2317
E-mail: [email protected]
www.hbcstudent.com
Online Services: Please visit our website atwww.firststudent.com for Certificates, EnrollmentCards (printable using Adobe Acrobat), CoverageReceipts, ID Cards, Claims Status and other services.
Please keep this Certificate as a general summary ofthe insurance. The Master Policy on file at theUniversity contains all of the provisions, limitations,exclusions and qualifications of your insurancebenefits, some of which may not be included in thisCertificate. The Master Policy is the contract and willgovern and control the payment of benefits.
Insured: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SR ID #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Policy #: 2011-200422-91 Underwritten by UnitedHealthcare Insurance Company Claims should be submitted to the company within 90 days after date of treatment.
Please mail all medical and hospital bills along with the insured student’s name andpatient’s name, ID number, address, and the name of the college or university underwhich the student is insured to the address listed on this card.
StudentResources
For Hospital pre-admission notification call UMR Care Management at1-877-295-0720.
This card is not a guarantee of coverage. For information concerning coverage, co-payment and claims instructions, please call Customer Service at the number listedon the front of this card.

Source: http://www.hbcstudent.com/brochures%20and%20enrollment%20forms/2011-200422-91-1brochure.pdf