Miami University. ( the Policyholder ) Student Health Insurance Plan

Transcription

1 Miami University ( the Policyholder ) Student Health Insurance Plan This brochure is only a brief description of the coverage available under policy series S30749NUFIC-OH-MU (Rev ). The Policy contains definitions, reductions, limitations, exclusions and termination provisions, some of which are not included in this brochure. Full details of the coverage are contained in the Policy on file at the University. If any discrepancy exists between the contents of this brochure and the Policy, the Policy will govern in all cases. Insurance and services provided by member companies of American International Group, Inc. Coverage may not be available in all jurisdictions and is subject to actual policy language. For additional information, please visit our website at Insurance underwritten by: National Union Fire Insurance Company of Pittsburgh, Pa., with its principal place of business in New York, NY ( the Company ) Administrator Policy # CHH Underwriter Reference # CAS Keep this brochure as a general summary of the insurance 1

2 Miami University Student Health Table of Contents Eligibility...3 Effective and Terminated Dates...4 Certificate of Creditable Coverage...4 Extension of Benefits...5 State Mandated Benefits...5 Definitions...5 Schedule of Benefits...9 Accidental Death and Dismemberment...8 Preferred Provider Network...13 Exclusions...13 Coordination of Benefits...14 Subrogation...14 Claim Procedures...15 Intercollegiate Sports Benefit...15 American Health Holding...16 Amacore Vision...17 In

3 ELIGIBILITY Miami University requires that all full-time students (taking 12 or more credit hours), graduate assistants (taking 9 credit hours) and all international students registered at Miami University s Oxford Campus carry health insurance. Students will be automatically enrolled in and charged premium for coverage under the Miami University Student Health Insurance Plan ( the Plan ) unless proof of comparable insurance coverage under another US healthcare plan is provided. Students who do not provide proof of comparable insurance coverage under another US healthcare plan by the waiver deadline of August 29, 2014, will be automatically enrolled in and charged the annual premium on their Bursar bill for coverage under the Plan. Students who have coverage under another comparable US healthcare plan and wish to waive coverage under the Miami University Student Health Insurance Plan may go to and follow the waiver instructions by the deadline date. After the August 29, 2014 waiver deadline date, there will be no waivers processed for the fall semester. The Spring Semester waiver deadline is February 15, 2015 and is only for new, incoming students to the University for the Spring Semester. Students who do not waive coverage by the deadline above will be enrolled in the Plan and may obtain their health insurance I.D. card at the Student Health Services Office. Note: Students enrolled in the Plan will also be automatically enrolled in and charged premium for coverage under a separate Intercollegiate Sports Accident Plan (see page 15 for details). A student who initially waived coverage under the Plan but subsequently experiences ineligibility under another creditable coverage may elect to enroll for coverage under the Plan within 31 days of the date of ineligibility under another creditable coverage. If you experience ineligibility under another creditable coverage, please proof of ineligibility to qualifier@studentinsurance.com STUDENT HEALTH INSURANCE PLAN COST PLAN COST Student Health Insurance * Annual Spring/Summer 8/1/2014-7/31/2015 (New Students Only) 1/1/15-7/31/2015 Student Only Spouse Child(ren) $1, $ $1, $ 1, $1, $ 1, *The Student Health Insurance Plan Cost for Student Only also includes premium for coverage under the Intercollegiate Sports Accident Policy (CAS ), and additional administrative fees and taxes. An eligible student must attend classes at the University for at least the first 31 days of the period for which he or she is enrolled. Eligibility requirements must be met each time premium is paid to continue coverage. The Company maintains the right to investigate student status and attendance records to verify that the Plan s eligibility requirements have been met. If it is discovered that the Plan s eligibility requirements have not been met, the Company s only obligation is to refund premium less any claims paid. 3

4 Students enrolled in the Plan may also enroll their eligible dependents on-line at Eligible dependents are the Covered Student s spouse residing with the Covered Student and the Covered Student s or spouse s child until the date such child attains age 26. Coverage may be extended to the Covered Student s or spouse s child until the child attains age 28, if the child: (a) is the natural child, stepchild or adopted child of the Covered Student or spouse; (b) is a resident of Ohio or a full-time student at an accredited public or private institution of higher education; (c) is not employed by an employer that offers any health benefit plan under which the child is eligible for coverage; (d) has been continuously covered upon the attainment of the limiting age; and (e) the child is not eligible for coverage under Medicaid or Medicare. A dependent may be enrolled under this Plan only when the student enrolls; or within 31 days of marriage, birth or adoption. EFFECTIVE AND TERMINATION DATES The Policy on file at the University becomes effective at 12:01 a.m. on August 1, 2014 and terminates at 11:59 p.m. on July 31, The coverage of an eligible student, including the student who initially waived coverage and subsequently enrolls within 31 days of ineligibility under another creditable coverage, who enrolls for coverage under this Plan shall take effect on the latest of the following dates: (1) the Policy Effective Date; (2) the date for which the first premium for the Covered Student s coverage is received by the Company; (3) the date the University s term of coverage begins; or (4) the date the student becomes a member of an eligible class of persons as described in the Description of Class section of the Schedule of Benefits in the Policy on file with the University. Insurance for a Covered Student will end at 11:59 p.m. on the first of these to occur: (a) the date the Policy terminates; (b) the date the Covered Student has failed to pay premium in accordance with the terms of the Policy or the Company has not received timely payment;(c) the date the Covered Student has performed an act or practice that constitutes fraud or made intentional misrepresentation of material fact under the terms of this Plan; (d) the date the Company has ceased to offer coverage in such market; (e) the date a graduated Covered Student, who was enrolled full-time and charged the annual premium, becomes employed and insured for employee benefits (premiums will be refunded on a pro-rata basis when written request is made and proof of employment is received); or (f) the date on which the Covered Student withdraws from the school because of: (1) entering the armed forces of any country (premiums will be refunded on a pro-rata basis (less any claims paid) when written request is made); or (2) withdrawal from school during the first 31 days of the period for which enrollment was made. If withdrawal from the University is for other than (e) or (f) above, no premium refund will be made. Students will be covered for the Policy term for which they are enrolled and for which premium has been paid. Except as specifically provided in the Policy, insurance for a Covered Student s dependent will end when insurance for the Covered Student ends. CERTIFICATE OF CREDITABLE COVERAGE Coverage under this Plan is creditable coverage under Federal Law. When coverage terminates, the Covered Person can request a Certificate of Creditable Coverage, within 24 months after cessation of coverage under this Plan, which is evidence of coverage under this Plan. In order to obtain a Certificate of Creditable Coverage, please log in to your student account at and select Student Options for obtaining a Certificate of Creditable Coverage or call NON-DUPLICATION OF COVERAGE If benefits are payable under more than one provision under the Policy, then benefits will be provided only under the provision providing the greater benefit. 4

5 EXTENSION OF BENEFITS If a Covered Person is confined to a Hospital on the date his or her coverage terminates, benefits will be payable for the Eligible Expenses incurred during the continuation of that Hospital confinement. Such benefits will be payable until the earliest of: (1) the date the Hospital confinement ends; (2) the end of the 90 day period following the date his or her coverage terminated; or (3) the date the applicable Maximum Amount is reached. The Extension of Benefits will apply only to the extent the Covered Person will not be covered under this Plan or any other health insurance policy in the ensuing term of coverage. STATE MANDATED BENEFITS This Plan covers all applicable state mandated benefits. Please see the Policy on file with the University for details. DEFINITIONS Accident means an occurrence which (a) is unforeseen; (b) is not due to or contributed to by Sickness or disease of any kind; and (c) causes Injury. Allowable Charges means the charges agreed to by the Preferred Provider Organization for specified covered medical treatment, services and supplies. Covered Person means a Covered Student and his or her dependent(s) insured under this Plan. Covered Student means any student of the Policyholder who is insured under this Plan. Doctor means: (a) legally qualified physician licensed by the state in which he or she practices; and (b) a practitioner of the healing arts performing services within the scope of his or her license as specified by the laws of the state of such practitioner. The term Doctor includes persons legally licensed for the practice of osteopathy, optometry, chiropractic, podiatry, dentistry, psychology, and nurse-midwifery while acting within the scope of that license as specified by the laws of the State of Ohio. The term also includes a mechanotherapist who was issued a certificate under section of the Revised Code and practices in accordance with rules adopted under section 4731 of the Revised Code, but only if that person completed educational requirements in mechanotherapy on or before November 3, The term Doctor does not include a Covered Person s immediate family member. Eligible Expense means a charge for any treatment, service or supply which is performed or given under the direction of a Doctor for the Medically Necessary treatment of a Sickness or Injury: (a) not in excess of the Reasonable and Customary charges; or (b) not in excess of the charges that would have been made in the absence of this coverage; (c) with respect to the Preferred Provider, is the Allowable Charge; (d) is the negotiated rate, if any and (e) incurred while this Plan is in force as to the Covered Person except with respect to any expenses payable under the Extension of Benefits provision. Emergency Medical Condition means a medical condition that manifests itself by such acute symptoms of sufficient severity, including severe pain, that a prudent layperson with average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following: (a) placing the health of the person afflicted with such condition or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (b) serious impairment to such person s bodily functions; or (c) serious dysfunction of any bodily organ or part of such person. When an Emergency Medical Condition occurs, the Covered Person may use the emergency system or any other telephone access system that is used to access pre-hospital emergency services. 5

6 Emergency Services means the following: (a) a medical screening examination, as required by federal law, that is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department, to evaluate an Emergency Medical Condition; (b) such further medical examination and treatment that are required by federal law to stabilize an Emergency Medical Condition and are within the capabilities of the staff and facilities available at the Hospital, including any trauma and burn center of the Hospital. Stabilize means the provision of such medical treatment as may be necessary to assure, within reasonable medical probability, that no material deterioration of the person s medical condition is likely to result from or occur during a transfer, if the medical condition could result in any of the following: (a) placing the health of the person afflicted with such condition or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (b) serious impairment to such person s bodily functions; or (c) serious dysfunction of any bodily organ or part of such person. In the case of a woman having contractions, stabilize means such medical treatment as may be necessary to deliver, including the placenta. Emergency does not include the recurring symptoms of a chronic illness or condition unless the onset of such symptoms could reasonably be expected to result in the complications listed above. Essential Health Benefits has the meaning found in section 1302(b) of the Patient Protection and Affordable Care Act and as further defined by the Secretary of the United States Department of Health and Human Services and includes ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. Hospital means a facility which meets all of these tests: (a) it provides in-patient services for the care and treatment of injured and sick people; (b) it provides room and board services and nursing services 24 hours a day; (c) it has established facilities for diagnosis and major surgery; (d) it is supervised by a Doctor; (e) it is run as a Hospital under the laws of the jurisdiction which it is located; and (f) it is accredited by the Joint Commission on Accreditation of Healthcare Organizations. Hospital does not include a place run mainly: (a) as a convalescent home; (b) as a nursing or rest home; (c) as a place for custodial or educational care; or (d) as an institution mainly rendering treatment or services for: mental or nervous disorders; or substance abuse. The term Hospital includes: (a) an ambulatory surgical center or ambulatory medical center; and (b) a birthing facility certified and licensed as such under the laws where located. It shall also include rehabilitative facilities if such is specifically for treatment of physical disability. Hospital also includes tax-supported institutions, which are not required to maintain surgical facilities. Immediate Family Member(s) means a person who is related to the Covered Person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister), or child (includes legally adopted or stepchild). Injury means bodily injury due to an accident which: (a) Results solely, directly and independently of disease, bodily infirmity or any other causes; (b) Occurs after the Covered Person s effective date of coverage; (c) Occurs while coverage is in force. All injuries sustained in any one accident, including all related conditions and recurrent symptoms of these 6

7 injuries, are considered a single Injury. Medical Necessity/Medically Necessary means that a drug, device, procedure, service or supply is necessary and appropriate for the diagnosis or treatment of a Sickness or Injury based on generally accepted current medical practice in the United States at the time it is provided. A service or supply will not be considered as Medically Necessary if: (a) it is provided only as a convenience to the Covered Person or provider; or (b) it is not the appropriate treatment for the Covered Person s diagnosis or symptoms; or (c) it exceeds (in scope, duration, or intensity) that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment; or (d) it is experimental/investigational or for research purposes; or (e) it could have been omitted without adversely affecting the patient s condition or the quality of medical care; or (f) it involves treatment of or use of a medical device, drug or substance not formally approved by the U.S. Food and Drug Administration (FDA); or (g) it involves a service, supply or drug not considered reasonable and necessary by the Healthcare Financing Administration Medicare Coverage Issues Manual; or (h)it can be safely provided to the patient on a more cost-effective basis such as outpatient, by a different medical professional or pursuant to a more conservative form of treatment. The fact that any particular Doctor may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service or supply Medically Necessary. Preventive Services mandated by the Patient Protection and Affordable Care Act and, in addition to any other preventive benefits described in the Policy, means the following services and without the imposition of any cost sharing requirements, such as deductibles, copayment amounts or coinsurance amounts to any Covered Person receiving any of the following: 1. Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force, except that the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention of breast cancer shall be considered the most current other than those issued in or around November 2009; 2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person involved; 3. With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and 4. With respect to women, such additional preventive care and screenings, not described in paragraph 1 above, as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. The Company shall update new recommendations to the preventive benefits listed above at the schedule established by the Secretary of Health and Human Services. Reasonable and Customary (R&C) means the charge, fee or expense which is the smallest of: (a) the actual charge; (b) the charge usually made for a covered service by the provider who furnishes it; (c) the negotiated rate, if any; and (d) the prevailing charge made for a covered service in the geographic area by those of similar professional standing. Geographic area means the three digit zip code in which the services, procedure, devices, drugs, treatment or supplies are provided or a greater area, if necessary, to obtain a representative cross-section of charge for a like treatment, service, procedure, device, drug or supply. Sickness means disease or illness including related conditions and recurrent symptoms of the Sickness which 7

8 begins after the effective date of a Covered Person s coverage. Sickness also includes pregnancy and complications of pregnancy. All Sicknesses due to the same or a related cause are considered one Sickness. ACCIDENTAL DEATH AND DISMEMBERMENT The Company will pay the benefit below for Injuries to a Covered Person: (a) caused by an Accident which happens while covered by this Plan; and (b) which directly, and from no other cause, result in any of the losses listed below within 180 days of the Accident that caused the Injury. The amount of this benefit is shown in the table below. For Loss Of: Maximum Amount Life...$10,000 Both Hands or Both Feet...$ 5,000 Sight of Both Eyes...$ 5,000 One Hand and One Foot...$ 5,000 One Hand and the Sight of One Eye... $ 5,000 One Foot and the Sight of One Eye...$ 5,000 One Hand or One Foot...$ 2,500 The Sight of One Eye...$ 2,500 Loss of a hand or foot means complete severance through or above the wrist or ankle joint. Loss of sight of an eye means the total, irrevocable loss of the entire sight in that eye. Severance means the complete separation and dismemberment of the part from the body. If a Covered Person suffers more than one loss as a result of the same Accident, the Company will pay only for the loss with the largest benefit. 8

9 Schedule of Benefits Aggregate Maximum Benefit per Policy Year: Unlimited *Deductible per Covered Person per Policy Year: $200* Student Health Center: $150 * (includes deductible amount applicable to Student Health Center) Out of Pocket Limit (In-Network and Out-of-Network Out of Pocket Limits apply separately): In-Network: $2,500 Out-of-Network: $5,000 The Out-of-Pocket Limit is reached when the amount of Eligible Expenses incurred by the Covered Person during the Policy Year, for which the Covered Person is responsible due to Covered Percentages less than 100%, reach the Out of Pocket Limit. The Out-of-Pocket Limit does not include the Policy Year Deductible; charges in excess of Reasonable and Customary; charges in excess of any specified maximum; or charges incurred for any services not covered under this Plan. When this benefit becomes applicable to a Covered Person during a Policy Year, Covered Percentages are increased to 100% for all Eligible Expenses incurred by the Covered Person in the remainder of that Policy Year up to any benefit maximum that may apply. INPATIENT In-Network Out-of-Network Room & Board, except ICU, limited to the average semi-private room rate. Hospital Miscellaneous, includes expenses incurred for anesthesia and operating room; laboratory tests and X-rays, (including professional fees); oxygen tent; drugs, medicines (excluding take-home drugs), dressings; and other Medically Necessary and prescribed Hospital expenses Surgery, when Injury or Sickness requires two or more surgical procedures which are performed through the same approach, and at the same time or immediate succession, the Company will pay only for the primary procedure performed. Assistant Surgeon Anesthetist Registered Nurse or Licensed Practical Nurse, for private duty nursing. Doctor s Visits (other than the Doctor who performed surgery or administered anesthesia), limited to one visit per day Physiotherapy, limited to one visit per day. Pre-admission Testing Psychiatric Conditions Paid the same as any other Sickness Paid the same as any other Sickness Alcoholism/Substance Abuse Paid the same as any other Sickness Paid the same as any other Sickness 9

10 OUTPATIENT In-Network Out-of-Network Surgery, when Injury or Sickness requires two or more surgical procedures which are performed through the same approach, and at the same time or immediate succession, the Company will pay only for the primary procedure performed Day Surgery Miscellaneous, when scheduled surgery is performed in a Hospital or outpatient facility or ambulatory surgical center, including use of the operating room, laboratory tests and x-ray examinations (including professional fees), anesthesia, infusion therapy; drugs or medicines and supplies, therapeutic services (excluding physiotherapy or take home drugs and medicines) Reasonable and Customary charges for day surgery miscellaneous expenses are based on the Outpatient Surgical Facility Charge Index. Anesthetist Doctor s Visits, limited to one visit per day per provider. More than one visit per day may be allowed, provided the 2nd and subsequent visits are not with the same Doctor. Benefits do not apply when related to surgery. For students paying the Student Health Center fee, services rendered at the Student Health Center will be payable at 100%, limited to one visit per day. Rehabilitation Care (physiotherapy, occupational therapy, chiropractic, cardiac/pulmonary, speech and hearing therapy), limited to one visit per day. Hospital Emergency Room, for use of emergency room and supplies. Urgent Care Expense X-rays and Laboratory Services (not otherwise covered under Preventive Services) (includes sickle cell testing up to $15 per test, one test per Policy Year, chlamydia screening and gonorrhea screening when services are rendered at the Student Health Center only). 80% of Allowable Charges 60% of R&C Charges OUTPATIENT In-Network Out-of-Network Chemotherapy/Radiation Therapy 10

11 CAT Scans/MRI/PET Scans Tests and Procedures, diagnostic services and medical procedures performed by a Doctor (other than Doctor s visits, physiotherapy, x-rays and laboratory procedures) (Not otherwise covered under Preventive Services) Injections when administered in the Doctor s office Prescription Medicines 80% of R&C Charges, not subject to the deductible(s)* *FDA-approved prescribed contraceptive drugs and devices will be payable at 100% of R&C Charges. Psychiatric Conditions Alcoholism/Substance Abuse Preventive Services Benefit: Includes preventive services such as screenings, exams, and immunizations as specified by the Patient Protection and Affordable Care Act (PPACA). To view a list of covered preventive services, log onto: 100% of Allowable Charges* *Not subject to deductible Paid the same as any other Sickness Paid the same as any other Sickness 60% of R&C Charges Kidney Dialysis (Medically Necessary treatment of acute or chronic kidney disease only) OTHER Ambulance 80% of R&C Charges 80% of R&C Charges Orthopedic Braces and Appliances (Benefits are payable only upon Doctor s written prescription) Durable Medical Equipment Consultant Doctor s Fees, when requested and approved by the attending Doctor Dental, for treatment of Injury to sound natural teeth only, up to $500 maximum per Injury per Policy Year. 80% of R&C Charges 80% of R&C Charges Dental Treatment Expense, one annual routine cleaning/x-rays and oral exam per Policy Year 80% of R&C Charges 80% of R&C Charges 11

12 Dental Treatment Expense (For Covered Persons age 19 and older) (Preventive Services): Oral Exam limited to one per Policy Year Full mouth x-ray limited to one procedure per Policy Year Routine Cleaning limited to one procedure per Policy Year 80% of R&C Charges 80% of R&C Charges Dental Treatment Expense (For Covered Persons under age 19 only): Oral Examination (Preventive) X-Ray and Pathology Prophylaxis and Fluoride Applications (Preventive) Amalgam Restorations Primary Teeth Amalgam Restorations Permanent Teeth Synthetic Restorations Oral Surgery (Includes local anesthesia and routine post-operative care) Extractions 50% of R&C Charges 50% of R&C Charges Benefits limited to a maximum amount of $2,500 per Policy Year Vision Care Expense*: Maximum Amount per Policy Year: Standard Plastic Lenses: o Single Vision: $50 o Bifocal: $50 o Trifocal: $50 o Lenticular: $50 o Progressive: $50 Frames: $100 Contact Lenses (In lieu of eyeglass lenses and frames) o Fit, Follow-up & Materials: Effective: $75 Medically Necessary: $75 60% of R&C 60% of R&C *Benefits are limited to one examination per Policy Year; one pair of lenses per Policy Year; and one frame per Policy Year. Home Health Care Expense, limited to a maximum of 100 visit per Policy Year Hospice Care Expense Skilled Nursing Facility, limited to a maximum of 90 days per Policy Year Repatriation of Remains $25,000 Medical Evacuation $25,000 12

13 PREFERRED PROVIDER NETWORK Welcome to Choice Care Network, a Preferred Provider Organization (PPO) Network. Use of this PPO network is voluntary; however, if the Covered Person uses a Choice Care Network Provider his or her financial responsibility (coinsurance) may be reduced. For more information or for a list of providers, please visit the Choice Care website at and click on Physician Finder ; or go to the AIG Educational Markets website at or call AIG Educational Markets at Providers may be periodically added or deleted as participants may change in the PPO Network. It is the Covered Person s responsibility to verify that a provider is a participating provider prior to services being rendered. EXCLUSIONS The Plan does not cover nor provide benefits for loss or expenses incurred: 1. as a result of dental treatment, or dental x-rays except as provided elsewhere in this Plan. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act. 2. for services normally provided without charge by this Policyholder s Health Service, Infirmary or Hospital, or by health care providers employed by this Policyholder or services covered by the Student Health Center fee. 3. for eye examinations, eyeglasses, contact lenses, or prescription for such except as provided elsewhere in the Policy; hearing aids; orthodontic braces and orthodontic appliances; or prescriptions or examinations for such. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act. 4. as a result of an Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by a commercial scheduled airline. 5. or Injury or Sickness resulting from war or act of war, declared or undeclared. 6. as a result of an Injury or Sickness for which benefits are paid under any Workers Compensation or Occupational Disease Law. 7. as a result of Injury sustained or Sickness contracted while in the service of the Armed Forces of any country. Upon the Covered Person entering the Armed Forces of any country, the Company will refund any unearned prorata premium. This does not include Reserve or National Guard Duty for training unless it exceeds 31 days. 8. for treatment provided in a government Hospital unless there is a legal obligation to pay such charges in the absence of insurance. 9. for cosmetic surgery. Cosmetic surgery shall not include reconstructive surgery when such surgery is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part and reconstructive surgery because of a congenital disease or anomaly of a covered dependent newborn child which has resulted in a functional defect. It also shall not include breast reconstructive surgery after a mastectomy. 10. for preventive treatment, testing, medicines, serums, vaccines, or vitamins except as specifically provided in this Plan. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act. 11. as a result of committing or attempting to commit an assault or felony or participation in a riot or civil commotion. 12. for elective treatment or elective surgery unless otherwise provided in this Plan. 13. after the date insurance terminates for a Covered Person except as may be specifically provided in the Extension of Benefits provision. 14. for any services rendered by a Covered Person s Immediate Family Member. 15. for any treatment, service or supply which is not Medically Necessary. 16. as a result of suicide or any attempt at suicide or intentionally self-inflicted Injury or any attempt at intentionally self-inflicted Injury, except where the suicide, attempted suicide, intentionally self-inflicted Injury or attempt at intentionally self-inflicted Injury is due to a Sickness covered under the Policy. 13

14 Exclusions (cont.) 17. for surgery and/or treatment of: acne; allergy testing; circumcision; corns, calluses and bunions; deviated nasal septum, including submucuous resection and/or other surgical correction thereof except for purulent sinusitis; family planning except as specifically provided; fertility tests; infertility(male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; impotence, organic or otherwise; sleep disorders, including testing thereof; and vasectomy. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act. 18. for routine physical examinations, health examinations or preschool physical examinations, including routine care of a newborn infant, well-baby care and related Doctor charges, except as specifically provided for in this Plan. This exclusion does not apply to Preventive Services mandated by the Patient Protection and Affordable Care Act. 19. for reversal of sterilization, artificial insemination or in vitro fertilization. 20. for Injury resulting from travel in or upon a snowmobile. 21. for voluntary or elective abortions. 22. for Injury resulting from: the practicing for, participating in, or traveling as a team member to and from inter collegiate, professional and semi-professional sports activity, including travel to and from the activity and practice; hang gliding; flight in an ultra light aircraft; parachuting; ballooning. 23. for treatment in the Hospital emergency room which is not due to an Emergency Medical Condition. 24. for the services of an assistant surgeon except as specifically provided under this Plan. 25. for treatment, services, drugs, device, procedures or supplies that are experimental or investigational. 26. for treatment, service or supply for which a charge would not have been made in the absence of insurance. COORDINATION OF BENEFITS The Company will coordinate benefits with other health carriers when duplicate coverage exists. Total payment from this coverage and other health coverages under which the Covered Person is enrolled shall not exceed 100% of the Reasonable & Customary Charges for covered services. SUBROGATION In the event any payments for benefits provided to a Covered Person are because of an Injury or Sickness caused by a Third Party s wrongful act or negligence, the Company, to the extent of that payment, will be subrogated to any recovery or right of recovery the Covered Person has against that Third Party, provided: (a) the Covered Person is entitled to payment for Hospital, surgical or medical services as the result of a Third Party settlement or court judgment; and (b) such settlement or judgment specified an amount or portion of payment that represents payment for such benefits; and (c) the Company has paid benefits to the Covered Person under this Plan for the same services or benefits covered by the settlement or judgment. The Covered Person agrees to make a decision on pursuing a claim against a Third Party within 30 days of the date the Company requires that the Covered Person provide notice of claim for the Injury or Sickness for which benefits under this Plan are sought and to notify the Company of his or her decision within such 30 day period. In the event the Covered Person decides not to pursue payment of claim against such Third Party, the Covered Person: (a) authorizes the Company to pursue, sue, compromise or settle any such payment of claim in the name of the Covered Person; (b) authorizes the Company to execute any and all documents necessary; and (c) agrees to cooperate fully with the Company in the prosecution of any such payment of claim. If the Company exercises its rights under this provision, it will recover no more than the amount paid under this Plan for such benefits. The Covered Person will execute and deliver such instruments and papers which may be needed to secure the rights described above. The Company will not pay or be responsible, without its written consent, for any fees or costs associated with the pursuit of a claim, cause of action or right by or on 14

15 behalf of a Covered Person against any Third Party or coverage. Subrogation means the Company s right to recover any benefit payments made under this Plan: (a) because of an Injury or Sickness to a Covered Person caused by a Third Party s wrongful act or negligence; and (b) which become recoverable from the Third Party or the Third party s insurer. The Company s right of subrogation will not be enforced until the Covered Person has been made whole, as determined by a court of law, as a result of Injury or Sickness. Third Party means any person or organization other than the Company, this Policyholder or the Covered Person. This provision will not apply if it is prohibited by law. INTERCOLLEGIATE SPORTS ACCIDENT INSURANCE PLAN Administrator Policy Number: EMH Underwriter Reference Number: CAS Students enrolled in the Plan will also be automatically enrolled in and charged premium for the Intercollegiate Sports Accident Insurance Plan. This is a separate policy underwritten by National Union Fire Insurance Company of Pittsburgh, Pa. and provides coverage for an Injury occurring while the Covered Student is participating in intercollegiate athletics. When such Injury occurs during a covered event, benefits will be payable up to a maximum of $5,000 per Injury. The first such expense must be incurred within 30 days after the date of the Accident causing the Injury. The benefits and provisions of the Intercollegiate Sports Accident Insurance Plan can be found at: In the event of Injury or Sickness: CLAIM PROCEDURE 1. Report to the Student Health Center for treatment; otherwise students should report to the nearest Doctor or Hospital. 2. Students can obtain a Company claim form from the Student Health Center or by logging into their student account on-line at Students should fill in the necessary information, have the attending Doctor complete his/her portion of the form, attach all itemized medical and Hospital bills and mail to: Claims AIG, Educational Markets Mail Center PO Box Overland Park, KS Claim forms can be accepted directly from Doctors or medical facilities if the claim form includes the name of the Covered Person, date of services, diagnosis, treatment procedure and billed charges. Proof of loss must be furnished to the Company within 90 days after the date of such loss. 15

16 Questions regarding enrollment, benefits, specific claim information and coverage terms should be directed to: AIG, Educational Markets Or by visiting our website at Visit the AIG Educational Markets Website to Review Account Information Check For: Receipt of Payment Verification of Insurance Date ID Card was Mailed On-Line Claim Form Completion Status of your Claim On-Line Enrollment for Dependents At AIG, we value the trust our customers have placed in us. That is why protecting the privacy of personal information is of paramount importance to us. For more information please go to our website at The following American Health Holding, Inc. and Amacore programs are not affiliated with National Union Fire Insurance Company of Pittsburgh, Pa. American Health Holding, Inc. 24-Hour Student Emergency Care Hotline (American Health Holding, Inc. is not affiliated with National Union Fire Insurance Company of Pittsburgh, Pa., and is not an insurance program) For confidential health care advice and information, 24 hours a day, 365 days a year, call toll-free Comprehensive Resources and Advice from Registered Nurses Direct access to an extensive Health Information Library, covering issues ranging from women s health to pediatrics. Detailed directories with topic codes and instructions for access to health-related topics. Choose to talk directly with a nurse. Discuss a current illness or health issue, or receive counseling on chronic conditions. Nurses can also educate callers about treatments, lifestyle choices and self-care strategies. Integrated phone access to specially trained personnel, trained to provide referral services for a number of health related concerns including mental health and/or substance abuse. 16

17 Amacore Vision A Product of The Amacore Group Inc. (Amacore Vision is not affiliated with National Union Fire Insurance Company of Pittsburgh, Pa.) Amacore Vision is one of the nation s leading vision care discount plans providing point-of-service savings at over thousands of eye care facilities nationwide including ophthalmologists (M.D.s), optometrists, opticians and optical outlets. This is not an insurance program but a discount plan. You will simply present your membership card at the time of service to receive your savings. How To Use Your Discount Card: Locate a provider by visiting Then call our toll-free number, and have our Patient Advocate call to confirm provider participation and program fee schedule. Please note: The free eye exam benefit is subject to participating providers. Present your member ID card at the time of your visit to the provider. You are responsible for the total bill, less the applicable savings, at the time service is rendered. 17