Collegiate Care Standard

Plan Detail

Plan Administrator: Trawick International | AM Best Rating: A "Excellent" | Underwriter: GBG Insurance Limited

Benefits


Collegiate Care Schedule of Benefits and Rates Collegiate Care Standard
Annual Maximum $500,000
Lifetime Medical Maximum No lifetime maximum
Deductible $500 Annual
Co-insurance In Network 80% of the Preferred Allowance
Co-insurance Out of Network 60% of URC
Physician Visits:
Student Health Center $0 Co-Pay
Primary Care Physician $30 Co-Pay
Specialist Visits $50 Co-Pay
Consultation Fee $50 Co-Pay
Hospital Room and Board Charges $250 Inpatient or Outpatient Co-Pay
Emergency Room $250 Co-Pay per visit (waived if admitted)
Maternity Up to $50,000
Pre-existing conditions Covered after 6 months
Prescriptions Pay and Claim; Covered up to the Policy Maximum. Must use Caremark Discount Card
Emergency Medical Evacuation/Repatriation $100,000
Return of Mortal Remains $100,000
You must actively attend/teach classes for the entire coverage period. Proof of active enrollment/contract will be requested at the time of a claim. This plan is fully earned and non-refundable on the effective date.

Eligibility

You are eligible for this coverage in the USA, if you have a current passport or visa and are temporarily residing outside your home country/country of permanent residence while actively engaged in education or research activities. You are “actively engaged“ in education, teaching or research activities if you are one of the following: F1/J1 valid Visa holder; Undergraduate – registered for and attending classes on a full-time basis; Graduate Student; Scholar or researcher who is invited by an educational organization; Students involved in education, educational activities, or research related activities. Students must actively attend classes for at least the first 31 calendar days after the date for which coverage is purchased. Home study, correspondence, internet classes and television courses do not fulfill the eligibility requirements. Your spouse and dependent children are also eligible for coverage if accompanying you and enrolled on your policy. For purposes of this insurance, if the Eligible Person’s home country or country of permanent residence (passport country) is different from the Eligible Person’s country of permanent residence (location in which the Eligible Person permanently resides), the Eligible Person will not be covered in either location. Permanent residents (green card holders) and US Citizens are not eligible for coverage under this Policy. Home Country will be that country which the Covered Person has declared to Us in writing as his or her Home Country. Injury or Accidents while on an Incidental trips to a country outside the USA, during the period of coverage are covered up to $1000..

When Coverage Begins And When Coverage Ends

Effective Date – The Effective Date of this Policy is the later of the following: 1. the date the Company receives a completed Application and correct premium for the Period of Insurance, or 2. the date requested on the Application, or 3. the day after applying online, or 4. the day after postmark when mailed. The Effective Date for your eligible spouse or dependents enrolled with you is your Effective Date, provided the Company receives the required premium for the spouse or dependent. If a spouse or dependent becomes eligible after your Effective Date, you have 30 days from the date such spouse or dependent first becomes eligible to enroll them and pay the applicable premium. Coverage Ends - Your coverage ends on the earliest of the following: 1. the date you cease to be eligible for coverage; or 2. the end of your term of coverage; or 3. the date requested on your application; or 4. the last day for which premium has been paid; 5. The date you no longer are affiliated with a school; 6. The date you return home; 7. After 364 consecutive covered days. Your spouse or dependent coverage will end at the earliest of: 1. the end of your term of COLLEGIATE CARE 5 coverage; or 2. the date requested on your application; or 3. the last day for which premium has been paid; 4. The date you no longer are affiliated with a school; 5. The date you return home; 6. After 364 consecutive covered days; or 7. the date a spouse or dependent is no longer eligible for coverage.

Accidental Death And

Dismemberment Principal Sum

Accidental Death Benefit – the plan pays $15,000 when your death occurs as a result of accidental injury. Loss of life must result within 90 days of the date of the accident causing such loss. Your coverage under the Policy must be in force on the date of the accident and when loss of life occurs. Dismemberment Benefit - If you sustain accidental injury that results in loss of a limb or sight the plan will pay the portion of the Principal Sum shown below. Loss must occur within 90 days of the accident causing such loss. In the event of more than one loss only one sum, the largest, will be paid. For injury resulting in the loss of:
  • Both hands or both feet or the sight of both eyes ;or One hand and one foot, one hand or one foot and the sight of one eye: $15,000
  • One hand or one foot or the sight of one eye: $7,500
“Loss of hand or foot” means severance at or above the wrist or ankle joint. “Loss of sight” must be entire and irrecoverable.

Medical Expense Benefits

Standard - $500,000 Annual Maximum for all Medical Expense Per Injury or Sickness Student: $100,000 Spouse/Domestic Partner: $100,000 Dependent Child $ 100,000 Preferred - $3,000,000 Annual Maximum for all Medical Expense Per Injury or Sickness Student: $500,000 Spouse/Domestic Partner: $100,000 Dependent Child: $100,000 The plan will pay benefits for covered expenses incurred by you for loss due to Sickness or injury, less any per injury or sickness deductible and subject to the Schedule: 1. The Maximum benefit for all services as shown in the Eligible Medical Expenses Section; 2. The Maximum amount for specific services as shown in the Schedule; and 3. Any coinsurance amount shown in the Schedule. Covered expenses are considered incurred when the covered service is rendered, provided there is a charge made for such service. The plan provides payment for services, procedures and supplies that are medically necessary. No benefits will be paid for expenses determined not to be medically necessary, including any or all days of hospital stay. The total payable for all covered expenses will not exceed the Maximum benefit shown in the Schedule; 13 weeks of treatment or to the end of the Period of Insurance, whichever comes first.

Eligible Medical Expenses include:

1. Physician Visit Benefit Inpatient -We will pay charges by a Physician for other than pre- or post-operative care for in-Hospital visits, up to the Maximum Benefit Amount shown in the Schedule of Benefits for Physician’s Visit – In-Hospital, unless it is covered through an all-inclusive case rate negotiated through the network. Outpatient - $30 per visit Co-Pay and after the Co-Pay We will pay charges by a Physician for office visits, up to the Maximum. 2. Specialist Outpatient Visit Benefit $50 per visit Co-Pay and after the Co-Pay We will pay charges by a Physician for office visits, up to the Maximum. 3. Consultant Physician Benefit When requested and approved by the attending physician $50 Co-Pay if, by reason of Injury or Sickness a Covered Person requires the services of a Consultant or Specialist when they are deemed necessary and ordered by an attending Physician for the purpose of confirming or determining a diagnosis. We will pay the amount incurred unless the cost of this service is included in a negotiated case rate with the provider or facility. 4. Hospital Room & Board Benefit Semi-Private Room Rate max 30 days and $250 Inpatient Co-Pay and $250 Outpatient Co-Pay - We will pay charges for the most common semi-private daily room rate for each day of the Hospital Stay. In computing the number of day’s payable, under this benefit, the date of admission will be counted, but not the date of discharge. Hospital Room and Board expenses will include floor nursing while confined in a ward or semi-private room of a Hospital and other Hospital services inclusive of charges for professional service and with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the Hospital’s average charge for semi-private room and board accommodation. 5. ICU Room and Board Benefit We will pay charges for each day of Intensive Care/Cardiac Care Unit confinement. This payment is in lieu of payment for the Hospital Room and Board charges for those days and includes nursing services. 6. Hospital Miscellaneous Expense Benefit Inpatient - We will pay for services, supplies and charges during a Hospital Stay. Miscellaneous services include services and supplies such as: the cost of the operating room; laboratory tests; X-ray examinations; anesthesia; drugs (excluding take-home drugs) or medicines; therapeutic services; and supplies; and blood and blood transfusions. Miscellaneous services do not include charges for telephone, radio, or television, extra beds or cots, meals for guests, take home items, or other convenience items. Outpatient-We will pay for services and supplies such as: the cost of the operating room; laboratory tests; X-ray examinations; anesthesia; drugs or medicine; therapeutic services; and supplies, on an Outpatient basis. 7. Surgeon/Surgery In or Outpatient Benefit $30 Surgeon PCP Co-Pay or $50 Co-Pay for Specialist. We will pay charges for a Physician, for primary performance of a surgical procedure. Two or more surgical procedures through the same incision will be considered as one procedure. If an Injury or Sickness requires multiple surgical procedures through the same incision, We will pay only one benefit, the largest of the procedures performed. If multiple surgical procedures are performed during the same operative session, but through different incisions, We will pay for the most expensive procedure and 50% of Eligible Expenses for the additional surgeries. 8. Assistant Surgeon Benefit If, in connection with such operation, a Covered Person requires the services of an Assistant Surgeon, We will pay the Covered Expense incurred. 9. Emergency Room Benefit $250 per visit Co-Pay. We will pay if the Covered Person requires Emergency Room treatment due to a Covered Loss resulting directly and independently of all other causes from a Covered Accident or Sickness. Emergency Room means a trauma center or special area in a Hospital that is equipped and staffed to give people Emergency treatment on an Outpatient basis. An Emergency Room is not a clinic or Physician’s office. 10. Pre-Admission Testing Benefit We will pay benefits for charges for Pre admission testing (inpatient confinement must occur within 3 days of the testing). 11. Anesthesia Benefit We will pay benefits for Anesthesia for pre-operative screening and administration of anesthesia during a surgical procedure whether on an Inpatient or Outpatient basis. 12. Diagnostic X-Ray and Laboratory Benefit We will pay if the Covered Person requires diagnostic x -ray and/or laboratory examinations and services due to a Covered Loss. 13. Physiotherapy/Chiropractic Expense Benefit We will pay benefits as described in the Schedule of Benefits for eligible Physiotherapy expenses incurred by the Covered Person. In no event will the Company’s Maximum liability exceed the Maximum stated in the Schedule of Benefits, as to Eligible Expenses during any Period of Insurance. 8 COLLEGIATE CARE For the purpose of this section, Physiotherapy means charges for physiotherapy if recommended by a Physician for the treatment of a specific Disablement or following hospitalization and administered by a licensed physiotherapist as an Outpatient, up to the Maximum amount shown in the Schedule of Benefits for the Outpatient Physiotherapy benefit. Charges include treatment and office visits connected with such treatment when prescribed by a Physician, including diathermy, ultrasonic, whirlpool, heat treatments, microtherm,chiropractic, adjustments, manipulation, acupuncture, or any form of physical therapy. 14. Ambulance Benefit When, by reason of Injury or Sickness, a Covered Person requires the use of a community or Hospital Ambulance in a Medical Emergency, We will pay up to $350 for transportation, within the metropolitan area in which the Covered Person is located at that time the service is used. Ambulance Service is transportation by a vehicle designed, equipped and used only to transport the sick and injured from home, the scene of the Accident or Medical Emergency to a Hospital or between Hospitals. Surface trips must be to the closest local facility that can provide the covered service appropriate to the condition. If there is no such facility available, coverage is for trips to the closest facility outside the local area. Air transportation is covered up to $350 when Medically Necessary because of a life threatening Injury or Sickness or if the Covered Person is in a rural area, then air ambulance transportation to the nearest metropolitan area will be considered an Eligible Expense. Air Ambulance is air transportation by a vehicle designed, equipped and used only to transport the sick and injured to and from a Hospital for inpatient care. Search and rescue charges are not covered. 15. Mental and Nervous Conditions Expense Benefit If a Covered Person requires treatment for a Mental or Nervous Condition, We will pay for such treatment as follows: Benefits for Inpatient Hospital Confinement -When a Covered Person requires Hospital Confinement for treatment of a Mental or Nervous Condition, We will pay the Covered Percentage of the Eligible Expenses incurred for such Hospital Confinement. Such confinement must be in a licensed or certified facility, including Hospitals. Benefits for Outpatient Services - We will pay the Eligible Expenses incurred for the Outpatient treatment of Mental and Nervous Conditions as defined. The Mental and Nervous Condition must, in the professional judgment of healthcare providers, be treatable, and the treatment must be Medically Necessary. Outpatient treatment and Physician services include charges made by an Outpatient treatment department of a Hospital or community mental health facility, or charges for services rendered in a Physician’s office. Treatment may be provided by any properly licensed Physician, psychologist or other provider as required by law. Biologically Based Mental Sickness means a mental, nervous, or emotional disorder caused by a biological disorder of the brain which results in a clinically significant, psychological syndrome or pattern that substantially limits the functioning of the person with the Sickness. 16. Alcohol and Drug Abuse Expense Benefit If a Covered Person requires treatment on account of alcoholism, Alcohol Abuse, Drug Abuse or drug dependency, We will pay for such treatment as follows: Benefits for Inpatient Hospital Confinement - When a Covered Person is confined as an inpatient in: (i) a Hospital; or (ii) a Detoxification Facility for the treatment of alcoholism, Alcohol Abuse, Drug Abuse or drug dependency, We will pay the Covered Percentage of the Eligible Expenses incurred for such Hospital Confinement. Such Confinement must be in a licensed or certified facility, including Hospitals. Benefits for Outpatient Services - We will pay the Covered Percentage of the Eligible Expenses incurred for the treatment of alcoholism, Alcohol Abuse, Drug Abuse, or drug dependency. Outpatient Treatment and Physician services include charges for services rendered in a Physician’s office or by an Outpatient treatment department of a Hospital, community mental health facility or alcoholism treatment facility, so long as the Hospital, community mental health facility or alcoholism treatment facility is approved by the Joint Commission on the Accreditation of Hospitals or certified by the Department of Health. The services must be legally performed by or under the clinical supervision of a licensed Physician or a licensed psychologist who certifies every three months that a Covered Person needs to continue such treatment. Alcohol Abuse means a condition that is characterized by a pattern of pathological use of alcohol with repeated attempts to control its use, and with significant negative consequences in at least one of the following areas of life: medical, legal, financial, or psychosocial. Drug Abuse means a condition that is characterized by a pattern of pathological use of a drug with repeated attempts to control its use, and with significant negative consequences in at least one of the following areas of life: medical, legal, financial, or psychosocial. Detoxification Facility means a facility that provides direct or indirect services to an acutely intoxicated individual to fulfill the physical, social and emotional needs of the individual by: monitoring the amount of alcohol and other toxic agents in the body of the individual; managing withdrawal symptoms; and motivating the individual to participate in the appropriate addictions treatment programs for Alcohol and Drug Abuse. 17. Emergency Dental Expense Benefit We will pay for expenses for emergency dental treatment due to Injury to Natural Teeth or to relieve pain. 18. Outpatient Prescription Drug Benefit - Pay and claim. Subject to deductible and coinsurance as well as exclusions. Must use Caremark Discount Card at Pharmacy. Prescription Drug means a drug which: 1. Under Federal law may only be dispensed by written prescription; and 2. is utilized for the specific purpose approved for general use by the Food and Drug Administration. The Prescription Drug must be dispensed for Outpatient use by the Covered Person: 1. on or after the Covered Person’s Effective Date and 2. Dispensed by a licensed pharmacy provider. 19. Durable Medical Equipment Expense Benefit If, by reason of Injury or Sickness, a Covered Person requires the use of Durable Medical Equipment, We will pay the Eligible Expenses incurred by a Covered Person for such Durable Medical Equipment. We pay the Eligible Expenses incurred by a Covered Person for the purchase or rental of such item. In no event shall we pay rental charges in excess of the purchase price. Any rental charges paid will be applied toward the cost of the purchase price if the equipment is purchased at a later date. If Durable Medical Equipment is purchased, it is Our property and is to be returned to Us, at Our expense, upon completion of a Covered Person’s need, if so requested by Us. We do not pay for the replacement of Durable Medical Equipment. Durable Medical Equipment means medical equipment that: 1. is prescribed by the Physician who documents the necessity for the item including the expected duration of its use; 2. can withstand long-term repeated use without replacement; 3. is not useful in the absence of an Injury or Sickness; and 4. can be used in the home without medical supervision. Charges made for artificial limbs, eyes, larynx, and orthotic appliances, but not for replacement of such items. 20. Emergency Medical Evacuation and Return of Remains Benefit When You suffer loss of life for any reason or incur a covered Sickness or Injury during the course of Your Period of Insurance, the following benefits are payable, up to the Maximum Benefit Amount shown in the Schedule of Benefits. Emergency Medical Evacuation: If the local attending Legally Qualified Physician and the Program Medical Advisor authorized travel assistance company determine that transportation to a Hospital or medical facility is Medically Necessary to treat an unforeseen Sickness or Injury which is acute or life threatening and adequate Medical Treatment is not available in the immediate area, the Transportation Expense incurred will be paid for the Usual and Customary Charges for transportation to the closest Hospital or medical facility capable of providing that treatment. Medical Repatriation: If the local attending Legally Qualified Physician and the authorized travel assistance company determine that it is Medically Necessary for You to return to Your primary place of residence because of an unforeseen Sickness or Injury which is acute or life-threatening, the Transportation Expense incurred within 30 days from the date of the Covered Loss, will be paid for Your return to Your primary place of residence or to a Hospital or medical facility closest to Your primary place of residence capable of providing continued treatment via one of the following methods of transportation, as approved, in writing, by the authorized travel assistance company: one-way Economy Transportation; commercial air upgrade (to Business or First Class), based on Your condition as recommended by the local attending Legally Qualified Physician and verified in writing and considered necessary by the authorized travel assistance company; or other covered land or air transportation including, but not limited to, commercial stretcher, medical escort, or the Usual and Customary Charges for air ambulance, provided such transportation has been pre-approved and arranged by the authorized travel assistance company. Transportation must be via the most direct and economical route. Return of Remains: In the event of Your death during the Period of Insurance, the expense incurred within 30 days from the date of the Covered Loss will be paid for minimally necessary casket or air tray, preparation and transportation of Your remains to Your primary place of residence. 21. Emergency Reunion - $5,000 Standard and $10,000 Preferred If You are traveling alone and will be hospitalized for more than 7 consecutive days and Emergency Evacuation or Medical Repatriation is not imminent, benefits will be paid to transport one person, chosen by You, by Economy Transportation, for a single visit to and from Your bedside. Reasonable travel and accommodation expenses incurred in relation to the Emergency Medical Reunion for hotel and meals to a Maximum of $50 per day up to the Maximum stated. 22. Maternity – Preferred Plan Only After a 12 month waiting period and conception must occur after the waiting period and while covered on the plan. The LMP is used to determine the date of conception. The Company will pay the Usual, Reasonable and Customary medical expenses in excess of the Deductible and Coinsurance as stated in the Schedule of Benefits, Maternity. In no event will the Company’s Maximum liability exceed the Maximum stated in the Schedule of Benefits Maternity, as to Eligible Expenses during any one period of individual coverage. Benefits will be payable for Eligible Expenses a Covered Insured or Spouse incurs before, during, and after delivery of a Child, including Physician, Hospital, laboratory, and ultrasound services. Coverage for the Inpatient postpartum stay for the Covered Person and her newborn Child in a Hospital, will, at a minimum, be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their guidelines for Perinatal Care. Coverage for a length of stay shorter than the minimum period mentioned above may be permitted if the Covered Person’s attending Physician determines further Inpatient postpartum care in not necessary for her or her newborn Child provided the following are met: In the opinion of the Covered Person’s attending Physician, the newborn Child meets the criteria for medical stability in the guidelines for Perinatal Care prepared by the Academy of Pediatrics and the American College of Obstetricians and Gynecologists that determine the appropriate length of stay based upon the evaluation of: The antepartum, intrapartum, postpartum course of the mother and infant; The gestational stage, birth weight, and clinical condition of the infant; The demonstrated ability of the mother to care for the infant after discharge; and The availability of post discharge follow up to verify the condition of the infant after discharge; and one (1) at-home post-delivery care visit is provided to the Covered Person at her residence by a Physician or Registered Nurse performed no later than forty-eight (48) hours following discharge of the Covered Person and her newborn Child from the Hospital. Coverage for this visit includes, but is not limited to: Parent education; Assistance in training in breast or bottle feeding; and Performance of any maternal or neonatal tests routinely performed during the usual course of Inpatient care for the Covered Person or newborn Child, including the collection of an adequate sample for the hereditary and metabolic newborn screening. At the Covered Person’s discretion, this visit may occur at the Physician’s office. Any newborn child must be enrolled in the coverage within 30 days of birth.

B. Outpatient Covered Expenses Include:

1. Surgery Services:
  • Surgeon
  • Anesthetist
  • Miscellaneous for Day Surgery benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; X-ray examinations; anesthesia; drugs or medicine; therapeutic services; and supplies.
2. Miscellaneous Hospital and Doctor Surgery Services payable as shown in the Schedule. 3. Doctor’s Visits 4. Physiotherapy 5. Medical Emergency - as defined. Benefits will be paid as shown in the Schedule. 6. Diagnostic X-ray Services - as shown in the Schedule. Separate maximums apply to positive and negative X-rays. Diagnostic X-rays are only those procedures identified in (CPT) as codes 70000-79999 inclusive. 7. Radiation Therapy 8. Laboratory Procedures - are only those procedures identified in Physicians’ Current Procedural Terminology (CPT) as codes 80000 - 89999 inclusive. 9. Tests and Procedures - a. Diagnostic services and medical procedures; b. Performed by a doctor; c. Excluding Doctor’s Visits; Physiotherapy; X-rays; and Laboratory Procedures. 10. Injections - a. When administered in the doctor’s office; and b. Charged on the doctor’s statement. 11. Prescription Drugs (including contraceptives) - Must use the Caremark Card 12. Chemotherapy 13. Mammography – one per year 14. Pap Smear for annual testing performed by FDA-approved gynecologic cytology screening technologies. 15. Maternity the date of the last menstrual period will determine the date of the loss. 16. Alcohol and Substance Abuse 17. Mental and Nervous Disorders 18. Durable Medical Equipment (DME)

C. Other Services Include:

1. Ambulance Services – up to $350 per sickness or injury 2. Braces and Appliances: a. When prescribed by a doctor; and b. When a written prescription accompanies the claim when submitted. Braces and appliances include durable medical equipment which: Is primarily and customarily used to serve a medical purpose, Can withstand repeated use, and Is not generally useful to a person in the absence of sickness or injury. No benefits will be paid for rental charges in excess of purchase price. 3. Consulting Physician when requested and approved by the attending doctor. Covered expenses will be paid under this benefit or under the Doctor’s Visits benefit, but not both on the same day. 4. Dental Treatment performed by a doctor and made necessary by injury or to relieve pain to natural teeth.

D. Additional Covered Services Include:

1. Repatriation - The plan pays for repatriation up to $50,000 while covered under the policy. This benefit will be paid for preparing and transporting your remains to your Home Country. 2. Emergency Medical Evacuation – the plan pays up to $50,000 for medical evacuation to your Home Country while you are covered under the policy. This benefit will be paid: a. During a minimum hospital stay; and b. When recommended and approved by the attending doctor. 3. Emergency Reunion - When an Insured Person is hospitalized for more than 7 days, and the Insured Person is eligible for a covered Emergency Medical Evacuation or Repatriation under this Policy, and the assistance company representative, appointed by the Company, and the attending Physician determines that Medical Emergency Evacuation or Repatriation is necessary and prudent for the Insured Person, the Company will arrange and pay for round trip economy-class transportation for one individual selected by the Insured Person, from the Insured Person’s current Home Country to the location where the Insured Person is hospitalized and return to the current Home Country. The benefits payable will include: Company will arrange and pay for round-trip economy-class transportation for a parent, spouse, sibling (over age 21) or legal guardian to the location where the Insured Person is hospitalized, and return, up to the maximum stated in Schedule of Benefits, Emergency Medical Reunion; Also Reasonable travel and accommodation expenses incurred in relation to the Emergency Medical Reunion for hotel and meals to a maximum of $50 per day up to the maximum stated in Schedule of Benefits, Emergency Medical Reunion. The period of Emergency Medical Reunion is not to exceed 14 days, including travel. All transportation in connection with an Emergency Medical Reunion must be pre-approved and arranged by the Assistance Provider. The male pronoun includes the female whenever used. Additional terms may be defined within the provision to which they apply. For the purposes of the Policy the capitalized terms used herein are defined as follows:

Definitions

Accident means an unforeseeable event which: 1) Causes Injury to one or more Covered Persons; and 2) Occurs while coverage is in effect for the Covered Person.
Benefit Period means the period of time from the date of the Accident causing the Injury or Sickness for which benefits are payable, as shown in the Schedule of Benefits, and the date after which no further benefits will be paid.
Child means the Covered Person’s natural Child, adopted Child (or Child placed in the Covered Person’s home for purposes of adoption), foster Child, stepchild, or other Child for whom the Covered Person has legal guardianship (proof will be required). A Child must reside with the Covered Person in a parent-Child relationship. NOTE: In the event the Covered Person shares physical custody of the Child with another parent, the requirement that the Child reside with the Covered Person will be waived.
Coinsurance means the percentage of Eligible Expenses for which the Company is responsible for a specified covered service after the Deductiblze, if any, has been met.
Company means GBG Insurance Limited. Also hereinafter referred to as We, Us and Our.
Co-Pay means a specified charge that the Covered Person is required to pay when a medical service is rendered
Cosmetic Surgery means the surgical alteration of tissue primarily for the improvement of appearance rather than to improve or restore bodily functions.
Covered Accident means an Accident that occurs while coverage is in force for a Covered Person and results in a Covered Loss for which benefits are payable.
Covered Loss or Covered Losses means an accidental death, dismemberment or other Injury covered under the Policy and indicated on the Schedule of Benefits.
Covered Person means a Person eligible for coverage as identified in the Enrollment/ Application , for whom proper premium payment has been made when due, and who is therefore a Covered Person under the Policy.
Covered Percentage means the percentage of a billed expense that would be considered to be the allowable amount for the particular service.

Definitions

Deductible means the dollar amount of Eligible Expenses which must be incurred and paid by the Covered Person before benefits are payable under the Policy. It applies separately to each Covered Person.
Dependent means a Covered Person’s lawful spouse, if not legally separated or divorced, or Civil Union Partner; unmarried Children under age 26.The age limitations will not apply to a Covered Person’s unmarried Child who is dependent on the Covered Person or other care providers for lifetime care and supervision, and incapable of self-sustaining employment by reason of mental or physical handicap that occurred before age 26. Proof of such dependence and incapacity must be furnished to the Company immediately upon enrollment or within 31 days of the Child reaching the age limitation. Thereafter proof will be required whenever reasonably necessary, but not more often than once a year after the 2-year period following the age limitation.
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 the Policy is in force.
Emergency means a Sickness or Injury for which the Covered Person seeks immediate medical treatment at the nearest available facility. The condition must be one which manifests itself by acute symptoms which are sufficiently severe (including severe pain) that without immediate medical care a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would cause: His life or health to be in serious jeopardy, or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn Child; His bodily functions to be seriously impaired; or A body organ or part would be seriously damaged.
Experimental/ Investigational means that a drug, device or medical care or treatment will be considered experimental/investigational if: The drug or device cannot be lawfully marketed without approval of the Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;
He, His and Him includes “she”, “her” and “hers”.
Health Care Plan means any contract, Policy or other arrangement for benefits or services for medical or dental care or treatment under: 1) Group or blanket insurance, whether on an insured or self funded basis; 2) Hospital or medical service organizations on a group basis; 3) Health Maintenance Organizations on a group basis. 4) Group labor management plans; 5) Employee benefit organization plan; 6) Professional association plans on a group basis; or 7) Any other group employee welfare benefit plan as defined in the Employee Retirement Income Security Act of 1974 as amended; or
Home Country means the country where a Covered Person has his or her true, fixed and permanent home and principal establishment
Hospital means an institution licensed, accredited or certified by the State that: 1) Operates as a Hospital pursuant to law for the care, treatment and providing in-patient services for sick or injured persons; 2) Is accredited by the Joint Commission on Accreditation of Healthcare Organizations; 3) Provides 24-hour nursing service by registered nurses (R.N.) on duty or call; 4) Has a staff of one or more licensed Physicians available at all times; 5) Provides organized facilities for diagnosis, treatment and surgery, either a) on its premises; or b) in facilities available to it, on a pre-arranged basis;
Hospital Stay means a Medically Necessary overnight confinement in a Hospital when room and board and general nursing care are provided for which a per diem charge is made by the Hospital.
Network Provider means a Physician, Hospital and other healthcare providers who have contracted to provide specific medical care at negotiated prices. The availability of specific providers is subject to change without notice. You should always confirm that a Network Provider is participating at the time services are required by GBG Assist or by asking the provider when you make an appointment for services.
Injury means bodily harm which results independently of disease or bodily infirmity, from an Accident after the effective date of a Covered Person’s coverage under the Policy, while the Policy is in force as to the person whose Injury is the basis of the claim. 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.
Inpatient means a Covered Person who is confined in an institution and is charged for room and board.
Insurance means the coverage that is provided under the Policy.
Intensive Care Unit means a cardiac care unit or other unit or area of a Hospital which meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.
Maximum Benefit means the largest total amount of Eligible Expenses that the Company will pay for the Covered Person as shown in the Covered Person’s Schedule of Benefits for an incident.
Medically Necessary means a treatment, drug, device, service, procedure or supply that is: 1) Required, necessary and appropriate for the diagnosis or treatment of a Sickness or Injury; 2) Prescribed or ordered by a Physician or furnished by a Hospital; 3) Performed in the least costly setting required by the condition; 4) Consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered. When specifically applied to Hospital confinement, it means that the diagnosis or treatment of symptoms or a condition cannot be safely provided on an Outpatient basis. The purchasing or renting of air conditioners, air purifiers, motorized transportation equipment, escalators or elevators in private homes, swimming pools or supplies for them, and general exercise equipment are not considered Medically Necessary..
Mental or Nervous Condition means any condition or disease, regardless of its cause, listed in the most recent edition of the International Classification of Diseases as a Mental Disorder on the date the medical care or treatment is rendered to a Covered Person.
Natural Teeth means the major portion of the individual tooth which is present, regardless of filings and caps; and is not carious, abscessed, or defective.
Non-Network Provider means a Physician, Hospital and other healthcare providers who have not agreed to any pre-arranged fee schedules. A Covered Person may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment are the Covered Person’s responsibility.
Occurrence means all losses or damages that are attributable directly or indirectly to one cause or one series of similar causes. All such losses will be added together and the total amount of such losses will be treated as one Occurrence without regard to the period of time or the area over which such losses occur.
Outpatient means a Covered Person who receives care in a Hospital or another institution, including: ambulatory surgical center; convalescent/ skilled nursing facility; or Physician’s office, for a Sickness or Injury, but who is not confined and is not charged for room and board
Outpatient Surgical Facility means a surgical or medical center which has (1) permanent facilities for surgery; (2) organized medical staff of Physicians and registered graduate Registered Nurses and (3) is authorized by law in the jurisdiction in which it is located to perform surgical services and is licensed (if no license is required, officially approved under law.
Period of Insurance means the period of time following the Covered Person’s Effective Date until the last date for which premium has been paid, or 364 days, whichever is less.
Physician means a person who is a qualified practitioner of medicine.
Physical Therapy means any form of the following administered by a Physician: (1) physical or mechanical therapy; (2) diathermy, (3) ultra-sonic therapy; (4) heat treatment in any form; or (5) manipulation or massage.
Policy means the Policy issued to the Policyholder, the Application of the Policyholder and the Participating Organization and any end endorsements, riders or amendments that will attach during the Period of Coverage.
Pre-Existing Condition means an Injury, Sickness, disease, or other condition during the 365 day period immediately prior to the date the Covered Person’s coverage is effective for which the Covered Person : 1) received or received a recommendation for a test, examination, or medical treatment for a condition which first manifested itself, worsened or became acute or had symptoms which would have prompted a reasonable person to seek diagnosis, care or treatment; or 2) took or received a prescription for drugs or medicine. Item (2) of this definition does not apply to a condition which is treated or controlled solely through the taking of prescription drugs or medicine and remains treated or controlled without any adjustment or change in the required prescription throughout the 180 day period before coverage is effective under the Covered Person’s Plan.
Pregnancy means the physical condition of being pregnant, including Complication of Pregnancy.
Prescription Drugs means drugs which may only be dispensed by written prescription under Federal law, and approved for general use by the Food and Drug Administration.
Registered Nurse means a licensed professional Registered Nurse (R.N.).
Sickness means Sickness or disease contracted and causing loss commencing while the Policy is in force as to the Covered Person whose Sickness is the basis of claim. Any complication or any condition arising out of a Sickness for which the Covered Person is being treated or has received Treatment will be considered as part of the original Sickness.
Spouse means lawful spouse, if not legally separated or divorced; or Civil Partner.
Substance Abuse means alcohol, drug or chemical abuse, overuse or dependency
Surgery or Surgical Procedure means an invasive diagnostic procedure; or the treatment of Sickness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.
Usual, Reasonable and Customary means the most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the area in which the charge is incurred. The most common charge means the lesser of: 1) The actual amount charged by the provider; or 2) The negotiated rate; or 3) The charge which would have been made by the provider (Physician, Hospital, etc.) for a comparable service or supply made by other providers in the same Geographic Area, as reasonable determined by Us for the same service or supply. “Geographic Area” means the three digit zip code in which the service, treatment, procedure, drugs or supplies are provided; a greater area if necessary to obtain a representative cross-section of charge for a like treatment, service, procedure, device drug or supply.
We, Our, Us means GBG Insurance Limited underwriting this insurance
You, Your, Yours, He or She means the Covered Person who meets the eligibility requirements of the Policy and whose insurance under the Policy is in force.

Extension of Accident and Sickness Medical Benefit and Benefit Period

If a Covered Person is hospital confined at term of coverage, benefits will continue to be paid until the earlier of either discharge from the hospital they are confined to or until the Maximum benefit has been paid, whichever occurs first. In no event will benefits continue beyond 30 days beyond the term of coverage or beyond the 13 week benefit period.

Coordination of Benefits Provision

If a Covered Person is covered for Benefits under the Policy, and is also covered for these Benefits under one or more other Plans, the benefits payable under the Policy will be coordinated with the benefits payable under all other Plans. Coordination of Benefits will be used to determine the benefits payable for a Covered Person for any Claim Determination Period if, for the Allowable Expenses incurred in that period would exceed those Allowable Expenses: The benefits that would be payable under the Policy without coordination; and The benefits that would be payable under all other Plans without the coordination of benefits provisions in those Plans. The benefits that would be payable under the Policy for Allowable Expenses incurred in any Claim Determination Period without Coordination of Benefits will be reduced to the extent required so that the sum of: Those required benefits; and All the benefits payable for those Allowable Expenses from all other Plans will not exceed the total of those Allowable Expenses. Benefits payable under all other Plans include the benefits that would have been payable had proper claim been made for them. However, the benefits of another Plan will be ignored when the benefits of the Policy are determined if: The Benefit Determination Rules would require the Policy to determine its benefits before that Plan; and The other Plan has a provision that coordinates its benefits with those of the Policy and would, based on its rules, determine its benefits after the Policy. When Coordination of Benefits reduces the total amount otherwise payable in a Claim Determination Period for a Covered Person, each benefit that would be payable in the absence of Coordination of Benefits will be reduced in proportion. The reduced amount will be charged against any applicable benefit limit of the Policy. We reserve the right to release to or obtain from any other insurance company or other organization or person, any information that, in Our opinion, We or it needs for the purpose of the Coordination of Benefits. When payments that should have been made under the Policy based on the terms of this provision have been made under any other Plans, We have the right to pay to any other organization making these payments the amount it determines to be warranted. Amounts paid in this manner will be considered benefits paid under the Policy. We will be released from all liability under the Policy to the extent of these payments. When an overpayment has been made by us, at any time, We will have the right to recover that payment, to the extent of the excess, from the person to whom it was made or any other insurance company or organization, as We may determine. Time Limits for Covered Loss Covered expenses will be paid as shown in the Schedule. 1. Due to Injury when: a. The accident causing the injury occurs before the end of your term of coverage; b. Treatment by a doctor begins within 30 days after the date of the accident causing injury; c. Treatment and services received are included under the definition of covered expenses; and d. All treatment is received during the period in which the covered person is eligible. 2. Due to your Sickness provided: a. Treatment by a doctor begins during the Period of Insurance; b. Treatment and services received are included under the definition of covered expenses; and c. All treatment is received during the period in which the covered person is eligible.

General Provisions

Right of Reimbursement/Subrogation - If a Covered Person recovers expenses for Sickness or Injury that occurred due to the negligence of a third party, We have the right to first reimbursement for all benefits We paid from any and all damages collected from the negligent third party for those same expenses whether by action at law, settlement, or compromise, by the Covered Person, the Covered Person’s parents if the Covered Person is a minor, or the Covered Person’s legal representative as a result of that Sickness or Injury. You are required to furnish any information or assistance, or provide any documents that We may reasonably require in order to exercise Our rights under this provision. This provision applies whether or not the third party admits liability. We are assigned the right to recover from the negligent third party, or his or her insurer, to the extent of the benefits We paid for that Sickness or Injury. You are required to furnish any information or assistance, or provide any documents that We may reasonably require in order to exercise our rights under this provision. This provision applies whether or not the third party admits liability.

Pre-Authorization

USA/Canada Toll Free: 1-877-916-7920 Upon completion Fax Authorization Form To: 1-905-669-2524 Pre-authorizations are subject to certification by the Plan Administrator. Pre-certification may be done by you, your doctor, a hospital administrator, or one of your relatives. Certain medical procedures or treatments will require a request form to be received by the Company or the Company’s authorized representative. This must be received a minimum of 5 business days prior to the scheduled procedure date if the procedure is elective, or within 48 hours after the initial admission if the admission is due to an emergency. Approval from the Company must be given prior to the commencement of the proposed medical treatment. If certification is received, covered charges will be paid as shown in the Schedule of Benefits. Failure to comply with prior authorization procedures will result in a 20% reduced benefit penalty, provided that the care is determined to be a procedure that would have been approved by the Plan Administrator. If upon review of medical records, it is determined to be a medical procedure which would not have been approved, the entire claim and all related charges will be denied. Pre-authorization is based on information provided to the Company at the time of request, and does not guarantee payment of benefits nor verify eligibility. Payment for services is subject to all terms, conditions, limitations and exclusions related to the member’s eligibility and subsequent medical review. Regardless of pre-authorization status, medical decisions concerning a course of treatment are solely between the doctor and you. Services requiring prior authorization are:
  • All Inpatient admissions and/or treatments, including but not limited to Admissions to an Inpatient Facility or Partial Hospitalization Unit; Emergencies must be postcertified within 48 hours of discharge or as soon as reasonably possible;
  • Any surgeries requiring general anesthesia (Outpatient or Inpatient);
  • Accidental Dental treatment for emergency dental repair of Natural Teeth damaged in an Accident;
  • Purchase or rental of Durable Medical Equipment;
  • RSV Immunization and other medications priced in excess of $1,000 per refill;
  • All cancer treatments/therapies;
  • Hemodialysis and Peritoneal Dialysis for renal failure;
  • Substance Abuse treatments/therapies;
  • Any condition, including chronic conditions that do not meet the above criteria, but are expected to accumulate $3,000 or more in Covered Expenses per Period of Insurance.