Plan Administrator: International Medical Group | AM Best Rating: A "Excellent" | Underwriter: Sirius Group, Sirius Specialty Insurance Corporation
| Maximum Limit | Student: $500,000; Dependent: $100,000 |
| Maximum Limit per Illness or Injury | Student: $300,000; Dependent: $100,000 |
| Deductible |
$100 per illness or injury Student health center: $5 copay per visit |
| Coinsurance |
Outside of the U.S.: Company pays 100% In PPO network or student health center within the U.S.: Company pays 100% Out of PPO network if within the U.S.: Company pays 80% of eligible expenses up to $5,000; then 100% thereafter |
| Hospital Room and Board | Average semi-private room rate, including nursing service |
| Intensive Care | After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally |
| Emergency Room Injury | After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally |
| Emergency Room Illness resulting in Hospitalization | After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally |
| Emergency Room Illness without Inpatient Admission |
After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally; Subject to additional $250 deductible |
| Mental or Nervous / Substance Abuse | Outpatient: $50 per day; $500 maximum limit; Inpatient: After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally up to $10,000 maximum limit; Student health center treatment: $0 |
| Prescription Drugs |
Inpatient: After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally Outpatient: 50% of actual charges 90 day dispensing maximum |
|
Physical Therapy (Medical order or treatment plan required) |
After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally; limit one visit per day |
| Local Ambulance | $350 per illness resulting in an inpatient hospitalization or injury |
| Dental | Non-emergency treatment at a dental provider due to an accident - $500 period of coverage limit per injury; Unexpected pain to sound, natural teeth - $350 period of coverage limit |
| Eligible Medical Expenses |
After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally |
|
Interfacility Ambulance Transfer (For services rendered in the U.S.) |
Company pays 100%. Transfer must be a result of an inpatient hospital admission |
| Emergency Medical Evacuation | $500,000 maximum limit |
| Emergency Reunion | $50,000 maximum limit |
| Return of Mortal Remains | $50,000 maximum limit |
| Political Evacuation and Repatriation | $10,000 maximum limit |
| Intercollegiate/Interscholastic/Intramural or Club Sports | $5,000 period of coverage limit per illness or injury |
| Incidental Trip Coverage | Up to a cumulative 14 days (available for non-U.S. residents only) |
| Pre-existing Conditions | Charges excluded until after 12 months of continuous coverage |
| Terrorism | $50,000 maximum limit |
| AD&D |
Student: $25,000 principal sum; Spouse: $10,000 principal sum; Dependent child: $5,000 principal sum Accidental dismemberment percentage of principal sum |
|
Personal Liability (Secondary to any other insurance) |
$10,000 combined maximum limit Injury to third person: subject to a $100 per injury deductible Damage to third person’s property: subject to a $100 per damage deductible |