Students are eligible for services when traveling more than 100 miles away from their Permanent Residence

Transcription

1 One Delaware Drive Salem, NH /7 On Call Global Response Center Global Academic Assistance Program Health Net Inc. Plan Description Eligibility for Participants: Students are eligible for services when traveling more than 100 miles away from their Permanent Residence On Call retains the medical discretion to limit two separate incidents per Participant, per year and to limit one emergency evacuation and/or repatriation attributable to any single medical condition of a Participant. For purposes of this Program, Permanent Residence shall mean the address where Participant s parent or legal guardian whom Participant is dependent upon, resides. If Participant is not a legal dependent, the Participant s Permanent Residence is the address listed on the Participant s driver s license or government issued identification. A Foreign National shall mean a citizen of any country other than the United States. A Foreign National s Permanent Residence shall mean the address listed on Participant s country issued passport/visa. All services must be provided by On Call. No claims for reimbursement will be accepted. Any expenses associated with these services are your responsibility except as provided within this Description of Services. Description of Services EMERGENCY TRANSPORTATION SERVICES Emergency Evacuation: If a Participant is more than 100 miles away from his/her Permanent Residence and is involved in an accident or suffers sudden illness and the medical facility the Participant is currently in is not adequate to treat the Participant in the opinion of On Call s Physician, On Call will make arrangements and pay for transfer to the nearest facility capable of providing adequate care. Coverage, Limits and Exceptions for these expenses are defined in Section (B) Terms and Conditions. Medically Necessary Repatriation: After initial treatment and stabilization while admitted in a hospital for an accident or sudden illness that occurs while the Participant is more than 100 miles away from his/her Permanent Residence, if On

2 Call s Physician determines that it is medically necessary, On Call will transport the Participant back to either of the following options: a. An appropriate hospital nearest Participant s school campus or Permanent Residence; or, b. Participant s school campus or Permanent Residence, for further medical treatment or to recover. Transportation must be by the most direct and economical route. A Participant who has been Medically Necessary Repatriated as defined is not eligible for a subsequent repatriation. Coverage, Limits and Exceptions for these expenses are defined in Section (B) Terms and Conditions. Repatriation of Mortal Remains: In the event of a Participant s death more than 100 miles away from his/her Permanent Residence, ON CALL will render every assistance possible to obtain necessary clearances and arrangements for the return of deceased remains and pay such reasonable expenses associated with the return. Services include arranging and paying for the following: location of a sending funeral home; preparation and transportation of the body from the site of death to the sending funeral home, to the airport and to the place of residence (if cremation) or to the receiving funeral home nearest the Permanent Residence; minimally necessary casket or air tray for transport; coordination of consular services (in the case of death overseas); procuring death certificates (limit 3); and transport of the remains from the airport to the receiving funeral home. Coverage, Limits and Exceptions for these expenses are defined in Section (B) Terms and Conditions. Visit by Family Member or Friend: If a Participant is traveling more than 100 miles away from his/her Permanent Residence alone and will be hospitalized for more than 7 days, at the Participant s request, On Call shall make and pay for economy travel arrangements for one (1) family member or friend to join the Participant. On Call shall also make suitable hotel arrangements and pay for hotel and meals up to the limit of coverage. Coverage, Limits and Exceptions for these expenses are defined in Section (B) Terms and Conditions Return of Dependent Children: If a Participant is hospitalized while traveling more than 100 miles away from his/her Permanent Residence more than seven (7) days, On Call will return the Participant s unattended minor children who are under 18 years of age and accompanying him/her on the trip, to their home, with an attendant if necessary. Coverage Limitations, Terms and Conditions for these expenses are defined in Section (B) Coverage Limitations, Terms and Conditions for Participants. Return of Traveling Companion: If a Participant s traveling companion loses previously-made travel arrangements due to a delay caused by the Participant s medical emergency or death while traveling more than 100 miles from his/her Permanent Residence, On Call will arrange one-way economy airfare to return the companion to his or her original departure point. Bereavement Reunion: in the event that a covered Participant dies while covered under the Program, ON CALL will arrange and pay for a family member to fly to the location of the deceased to identify and accompany the remains back to the Participant s Home Country.

3 Return of Personal Belongings: in the event of a Participant s death or evacuation that prevents the participant from returning to his/her Program, ON CALL will arrange and pay for shipment of personal effects to the Participant s home or family. MEDICAL ASSISTANCE SERVICES Medical, Behavioral Health, Dental and Pharmacy Referrals: On Call shall provide, at the Participant s request, referrals to medical, behavioral health or dental professionals and pharmacies in the given geographic area locations of western style medical facilities and English speaking doctors, dentists and other health care providers in an area served by On Call to the extent possible. Medical Monitoring: On Call shall monitor the Participant s conditions when hospitalized and provide ongoing updates to the Participant s family. Depending upon the medical and/or geographical situations, On Call may retain the services of consulting physicians/nurses and/or other medical professionals with relevant areas of expertise to assist in the monitoring of the Participant s condition. Deposits, Advances and Guarantees: Deposits, advances and guarantees will be provided for, but not limited to, hotels, airlines, and other like providers to secure service for Participant when traveling more than 100 miles from his/her Permanent Residence. Any advances of funds on behalf of the Participant shall be charged to the Participant s credit card at the time of service. Dispatch of Medicine: On Call shall dispatch to the Participant prescription medicine, when not locally available and legally permissible, upon the written authorization of Participant s Primary Physician. The Participant is responsible for any expenses incurred in this regard, including but not limited, to the cost of the pharmaceuticals, shipping cost, taxes or other import/export duties. These expenses will be billed to the Participant s credit card prior to shipping. Dispatch of Physician/Nurse: When a Participant is more than 100 miles away from his/her Permanent Residence, On Call may at its sole discretion dispatch to the Participant s location a physician or other health care professional to assist in determining the medical condition and suitability to travel to a Participant who has been hospitalized. Any transportation arrangement expenses to dispatch a physician/nurse to the patient and/or physician/nurse service charges on behalf of the Participant shall be charged to the Participant s credit card at the time of service. TRAVEL ASSISTANCE SERVICES Travel Assistance: At the Participant s request, On Call shall assist Participant once a trip has started with changing airline, hotel or car rental reservations Translation and Interpreters: On Call will provide foreign language assistance over the telephone or up to one-page translations submitted via fax. On Call will also provide referrals to local translators and interpreters. Fees for these types of translators are the responsibility of the Participant.

4 Emergency Cash Advance Assistance: On Call shall provide assistance to Participants by arranging for the forwarding of funds from Participant s credit cards or family members. Any fees associated with the transfer of funds will be the responsibility of the Participant. Replacement of Lost Traveling Documents Assistance: On Call shall provide assistance to Participants by arranging for the replacement of passports, airline documents, birth certificates and other travel-related documents. Any fees required for the acquisition or forwarding of these documents is the responsibility of the Participant. Emergency Message Forwarding Assistance: In the event a Participant is unable to reach an employer, family member or traveling companion, On Call shall forward a message via telephone to the intended party. Legal Referral: If a Participant is more than 100 miles away from his/her Permanent Residence and is arrested, or requires the services of an attorney, On Call shall arrange for an initial telephone consultation with an attorney without charge to Participant. If needed, a Participant will be referred to an attorney in the appropriate geographical area. Fees and costs charged by the referred attorney shall be the responsibility of Participant. Lost Luggage Assistance: On Call shall assist the Participant with the tracking of luggage lost in transit. Bail Bond Assistance: On Call can assist in securing bail bond services in all available locations Pre-Trip Information: On Call shall provide up-to-date information either by , fax or over the phone regarding required vaccinations, health risks, travel restrictions and weather conditions for global destinations worldwide Coverage Limitations, Terms and Conditions COVERAGE TERMS All benefits listed below are subject to the maximum Combined Single Limit (CSL) of $500,000 per Participant, per event. Emergency Evacuation/Medically Necessary Repatriation Up to $500,000 CSL Repatriation of Mortal Remains Up to $10,000 Return of Dependent Children Up to $2,500 Return of Traveling Companion Up to $2,500 Bereavement Reunion Up to $2,500 Return of Personal Belongings Up to $1,000 If traveling alone: Visit by a Family Member or Friend Up to $2,500 The Following Expenses Are Not Covered: a. Services other than those indicated herein.

5 b. SERVICES RENDERED WITHOUT THE AUTHORIZATION AND/OR INTERVENTION OF ON CALL. c. Services provided for a Participant for which no charge is normally made. d. Expenses incurred if the original or ancillary purpose of the Participant s trip is to obtain medical treatment. e. Participation in a declared or undeclared act of war, civil disturbance or insurrection or an accident occurring while the Participant is serving on full-time or active duty in the Armed Forces of any country. f. Participation in an authority flight in aircraft being used for experimental purpose, or in military aircraft (except the Military Aircraft Command of the United States or similar air transport Services Account of other) or while serving as a member of the crew of any aircraft. g. Any services provided to an injured person where the Participant is entitled to receive reimbursement for such expenses under any group insurance program maintained by the Participant s insurance company or employer. h. Routine or non-disabling medical problems, such as simple fractures, or sickness, which can be treated by local doctors and do not prevent the injured person from continuing the trip or returning home. i. A Participant on an organ transplant list prior to enrollment will not be entitled to a transport for that transplant. j. Any expenses incurred while traveling within 100 miles of an eligible Participant s Permanent Residence. Limitations: All legal actions arising under this Agreement shall be barred unless written notice thereof is received by On Call within one year from the date of event giving rise to such legal action. On Call cannot be held responsible for failure to provide services or for delays caused by strikes or conditions beyond its control, including but not limited to flight conditions, or where rendering of service is prohibited by local laws or regulatory agencies. Participant may be required to release On Call or any health care provider from liability during emergency evacuation and/or repatriation. Without limiting the foregoing, On Call s actions and obligations under this Agreement are ministerial in nature, and all medical care is provided by medical professionals ultimately selected by a Participant and in no event is the responsibility of On Call. On Call is not liable for any malpractice performed by a local doctor, health care provider or attorney. On Call, at its sole discretion, will assist Participants on a fee for service basis for interventions falling under the Limitations and Uncovered Services. On Call reserves the right, at its sole discretion, to request additional financial guarantees or pre-payment or indemnification from the Participant prior to rendering such service on a fee for service basis.