Intercollegiate Sports Injury Only Insurance Plan. Designed Especially for the

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1 Intercollegiate Sports Injury Only Insurance Plan Designed Especially for the State of Washington and Northwest Athletic Association of Community Colleges Policy # US NWAA15

2 Intercollegiate Sports Injury Only Plan The following is a brief description of the Injury medical expense benefits for athletic team participants of the State of Washington and Northwest Athletic Association of Community Colleges. Complete details of coverage are in the Certificate issued to the Colleges. It may be inspected during business hours at the business office of the College. The following provisions are applicable to each Insured Person: 1) Who is eligible for insurance under the group policy? Intercollegiate Student Athletes, Student Coaches, Student Managers, Student Trainers and Student Cheerleaders. Also eligible are prospective athletes and up to two chaperones for those prospective athletes. Students must actively attend classes for at least the first 31 days beginning with the first day for which coverage is purchased. 2) When are eligible insureds covered? Student Athletes, Student Coaches, Student Managers and Student Trainers are covered for events and activities that are authorized by, organized by or directly supervised by an official representative of the Certificateholder. Student Cheerleaders are covered for activities performed as part of the cheer unit for an intercollegiate sport team competition authorized by, organized by and directly supervised by an official coach or advisor of the Certificateholder. Practice sessions and pep rallies are also qualifying events when: a) authorized by, organized by and directly supervised by an official coach or advisor of the Certificateholder, other than an Insured; and b) in preparation for an intercollegiate sport team competition. Prospective athletes and their chaperones are covered for activities during, and directly related to an official visit for which the athlete was invited by the Certificateholder. 3) On what date does coverage begin? Coverage begins as of the date that the individual is accepted by the Certificateholder as a registered student and becomes a member of an eligible class. In no event, however, will insurance be deemed to commence prior to the effective date of the Certificate. 4) On what date does coverage terminate? Coverage terminates as of the first to occur of the following dates: a) The date that the individual ceases to be eligible for Coverage; b) The plan Termination Date. 5) Does coverage include benefits for stress fractures, heat stroke, strains, twists, and other injuries directly related to participation in and travel to and from intercollegiate athletic events under college supervision? Yes, coverage includes conditions which result from other than accidental bodily injury, provided they are the result of the practice and play of a covered athletic activity and the student-athlete has been released to participate in practice or play by a legally qualified physician. Medical Expense Benefits When covered Injuries result in treatment by a Legally Qualified Physician beginning within 90 days after the date of the accident, we will pay the Medical Expense incurred in excess of the $ per injury Medical Deductible. Benefits shall not exceed the Usual and Customary Charges. Eligible Medical Expenses are as follows: (a) Treatment by a Legally Qualified Physician; (b) Care or services from a Hospital or Ambulatory Surgical Center; (c) Services from a registered graduate nurse (RN or LPN) not related to the Insured by blood or marriage; (d) Professional ambulance service; (e) Orthopedic appliances. Only covered Medical Expense incurred by the Insured within 104 weeks from the date of the accident is covered. Benefits for any one accident shall not exceed, in the aggregate, the Medical Benefit ($25,000 for all eligible Insureds except chaperones; $10,000 for chaperones). Accidental Death and Dismemberment Benefits If, within 365-days from the date of an Accident covered by this Plan, Injury from such Accident, results in Loss listed below, we will pay the percentage of the Principal Sum set opposite the loss in the table below. If the Covered Person sustains more than one such Loss as the result of one Accident, we will pay only one amount, the largest to which he is entitled. This amount will not exceed the Principal Sum which applies for the Covered Person. Loss Percentage of Principal Sum Loss of Life...100% Loss of Both Hands...100% Loss of Both Feet...100% Loss of Entire Sight of Both Eyes...100% Loss of One Hand & One Foot...100% Loss of One Hand & Entire Sight of One Eye...100% Loss of One Foot & Entire Sight of One Eye...100% Loss of One Hand...50% Loss of One Foot...50% Loss of Entire Sight of One Eye...50% Loss of Thumb & Index Finger of the Same Hand... 25% Loss of a hand or foot means complete Severance through or above the wrist or ankle joint. Loss of sight means the total, permanent loss of sight of the eye. The loss of sight must be irrecoverable by natural, surgical or artificial means. Loss of a thumb and index finger means complete Severance through or above the metacarpophalangeal joints (the joints between the fingers and the hand). Severance means the complete separation and dismemberment of the part from the body. Heart and Circulatory Malfunction Benefit If an Insured suffers Loss of Life resulting from Heart or Circulatory Malfunction (as defined), within 90 days from the date of participating in a scheduled game or supervised practice relating to the first diagnosis, we will pay, on behalf of the Insured, a lump sum benefit in the amount of $10,000.

3 BASIC MEDICAL EXPENSE BENEFITS Benefits will be paid for each service as scheduled below subject to the overall Maximum Benefit, provided that treatment is received by a qualified, licensed physician. Maximum Benefit Deductible (Eligible medical expenses payable under any other insurance policy or service contract will be used to satisfy or reduce the Medical Deductible. *URC means Usual, Reasonable and Customary Each Injury $25,000 for all Insureds except Chaperones. Maximum Benefit amount for Chaperones is $10,000. $250 per Injury Covered Medical Expenses: Hospital Room & Board (including daily room rate and general nursing care) Hospital Miscellaneous Expenses (the cost of preadmission testing, the operating room, laboratory tests, x-ray examinations, anesthesia, drugs (excluding take home drugs) or medicines, therapeutic services, blood and plasma, and supplies. In computing the number of days payable under this benefit, the date of admission will be counted, but not the date of discharge) Intensive Care Day Surgery Miscellaneous (including the cost of the operating room; laboratory tests and x-ray examinations, including professional fees; anesthesia; drugs or medicines; and supplies) Surgeon s Fees (no more than one surgical procedure will be covered when multiple procedures are performed through the same incision or in immediate succession) Assistant Surgeon (payable only when required by Hospital) Anesthetist Physician s Visits (benefits are limited to one visit per day and do not apply when related to surgery) Consultant Physician Fees (when requested and approved by the attending Physician) Outpatient Physiotherapy (benefits are limited to one visit per day) Registered Nurse s Services (private duty nursing care) Emergency Room Ambulance X-Ray and Laboratory Tests Test & Procedures (diagnostic services and medical procedures performed by a Physician, other than Physician s Visits, Physiotherapy, x-rays and lab procedures) Braces and Appliances Prescription Drugs Dental Treatment (made necessary by Injury to Natural Teeth) Semi-Private Room Rate Covered Charges

4 Full Excess Medical Expense If an Injury to the Covered Person results in his incurring Eligible Expenses for any of the services in the Schedule of Benefits, we will pay the Eligible Expenses incurred, subject to the Deductible Amount and Coinsurance Percentage (if any), that are in excess of Expenses payable by any other Health Care Plan, regardless of any Coordination of Benefits provision contained in such Health Care Plan. Definitions Accident means a sudden, unforeseeable external event which: (1) Causes Injury to one or more Covered Persons; and (2) Occurs while coverage is in effect for the Covered Person. Covered Person means a person eligible for coverage as identified in the Application for whom proper premium payment has been made, and who is therefore insured under this Plan. Doctor means a licensed practitioner of the healing arts acting within the scope of his license. Doctor does not include: (1) The Covered Person; (2) The Covered Person s spouse, child, parent, brother, or sister; or (3) A person living with a Covered Person. Eligible Expenses means the Usual, Reasonable and Customary charges for services or supplies which are incurred by the Covered Person for the Medically Necessary treatment of an Injury. Eligible Expenses must be incurred while this Plan is in force. Heart or Circulatory Malfunction means disease or illness of the heart or circulatory system which: (a) is first diagnosed and treated while the Insured s coverage under the Plan is in force and occurs in a scheduled game or supervised practice, within 24 hours after participation; and (b) the Insured has not before such participation been medically advised of/or has received any medical treatment for such heart or circulatory malfunction. Injury means bodily harm which results, directly and independently of disease or bodily infirmity, from an Accident. All injuries to the same Covered Person sustained in one accident, including all related conditions and recurring symptoms of the Injuries will be considered one Injury. Medically Necessary means the service or supply is: (1) Prescribed by a Doctor for the treatment of the Injury; and (2) Appropriate, according to conventional medical practice for the Injury in the locality in which the service or supply is given. Usual, Reasonable and Customary means: (1) With respect to fees or charges, fees for medical services or supplies which are; (a) Usually charged by the provider for the service or supply given; and (b) The average charged for the service or supply in the locality in which the service or supply is received; or (2) With respect to treatment or medical services, treatment which is reasonable in relationship to the service or supply given and the severity of the condition. Exclusions and Limitations No benefits will be paid for loss or expense caused by, contributed to, or resulting from: 1. Suicide, attempted suicide or intentionally self-inflicted injury while sane or insane (in Missouri, while sane only); 2. Injuries caused by an act of declared or undeclared war; 3. Injuries resulting from the Insured s engagement in or attempt to commit a felony or being engaged in an illegal occupation; 4. Injuries received while under the influence of any controlled substance, unless administered on the advice of a Legally Qualified Physician; 5. Injuries received while intoxicated; 6. Injuries covered by workers compensation or employer s liability laws; 7. Injuries received while in the armed service (upon notice to us of entry into an armed service, the pro rata premium will be refunded); 8. Injuries received while acting as a pilot or crew member; 9. Injuries received while traveling as a passenger by air, except as specifically provided herein; 10. The cost of dental treatment, except as specifically provided for injuries to natural teeth; 11. The cost of eyeglasses, contact lenses or examinations for either. 12. Coverage for student athletes, student coaches, student managers and student trainers is not provided for activities that are not directly a part of an intercollegiate sport, such as camps, clinics and other events not conducted by the Policyholder. 13. Coverage for cheerleaders does not include any activities that are not directly associated with the activities of an intercollegiate sport team, such as camps, clinics, national competitions, fund-raisers, alumni events and other events not conducted by the Certificateholder. 14. Travel coverage for prospective athletes and their chaperones is only effective for activities conducted under the direct supervision of an official representative of the Certificateholder. Detach and Retain for your records Identification Card United States Fire Insurance Company Student Name: Please reference the SSN as the student s insurance ID number. The student whose name appears above has been insured under a pian issued to the: State of Washington and Northwest Athletic Association of Community Colleges.

5 Claim Procedure In the event of Injury, the student should: 1) Report to a Physician or Hospital. 2) Obtain a claim form from the College. Please submit one claim form for each Injury. Mail the completed claim form, all medical bills and your Primary Carrier s explanation of benefits to the address below. 3) File claim within 90 days of Injury. Submit All Claims and Claims Inquiries to: SUMMIT AMERICA INSURANCE SERVICES PO BOX Overland Park, KS Call Toll Free or claims related questions to: Plans are underwritten by the United States Fire Insurance Company. Fairmont Specialty and Crum & Forster are registered trademarks, of United States Fire Insurance Company. The Crum & Forster group of companies is rated A (Excellent) by AM Best Company 2013 Please keep this Brochure as a brief summary of the insurance. The exact benefits, limitations, and exclusions governing this Plan are contained in the Certificate (GA-26932) issued to Washington State Community Colleges onsite at the school. The Certificate will prevail in the event of any discrepancy between this Brochure and the Certificate. CLAIM FILING INSTRUCTIONS This coverage is excess to all other insurance. If the patient has other medical insurance, please submit the primary carrier s explanation of benefits and all medical bills including the student's name, social security number, address and name of the school the student attends to: Summit America Insurance Services, PO BOX 25936, Overland Park, KS Electronic Payor # NOTICE TO HEALTH CARE PROVIDERS: Claim status can be checked online at For information regarding plan benefits, eligibility or claim instructions please call Summit America Insurance Services at (877) This card is not a guarantee of coverage.

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