Student Health Advantage Platinum - Including USA

Plan Detail

Plan Administrator: International Medical Group | AM Best Rating: A "Excellent" | Underwriter: Sirius Group, Sirius Specialty Insurance Corporation

PPO Network(Within USA or Canada): 80% of Eligible Expenses after the Deductible up to $5,000, then 100% up to policy max.
Eligibility: A Full time Student & Non US Citizen Age 14-64 travelling USA to study
Coverage length: Min 3months to 12months
Provider Network: PPO Providers are contracted separately through First Health Group Corp
Renew Online: Provided there is no break in coverage, the plan may be renewed for up to five years
Cancel: Before effective date full refund and after policy effective date unused portion of premium minus $50 cancellation fees.
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Benefits Description Exclusions Renew Online Cancel Claims Provider Network

Benefits

Coverage Limit / Maximum Amount for Eligible Medical Expenses

Period of Coverage

Maximum Limit: 365 days

Maximum Limit

Insured Person: $1,000,000

Spouse and Child: $100,000

Maximum Limit per Illness or Injury

Insured Person: $500,000

Spouse and Child: $100,000

Area of Coverage

Worldwide excluding Insured Person’s Country of Residence

Benefit Plan Features

Benefit Levels

United States	United States	International
In-Network	Out-of-Network	International

Deductible for Eligible Medical Expenses

Deductible

Per Illness or Injury

$25

$50

$25

Coinsurance for Eligible Medical Expenses

Coinsurance

In addition to Deductible

Plan pays 100%
Insured pays 0%

Plan pays 80%
Insured pays 20%

Plan pays 100%
Insured pays 0%

Out of Pocket Maximum

$1,000

Student Health Center

Copayment per visit

Not subject to Deductible

Coinsurance

Plan pays 100%
Insured pays 0%

Pre-certification

Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met.
Medical Evacuation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION provision for complete requirements and coverage.
Maternity: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
All other Treatments & supplies: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
Deductible is taken after reduction.
Coinsurance is applied to remainder of the reduced amount.
Refer to PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification.

Pre-existing Conditions

Charges are excluded until the Insured Person has maintained 6 months of continuous coverage under this insurance.

Inpatient or Outpatient Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Benefit	In-Network	Out-of-Network	International
Physician Visits / Services Maximum Visits per Day: 1 Surgery is not subject to the maximum visit limit	100%	80%	100%
Hospital Emergency Room Injury: Not subject to Emergency Room Deductible Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission.	100%	80%	100%
Hospitalization / Room & Board Average semi-private room rate Includes nursing, miscellaneous and Ancillary Services	100%	80%	100%
Intensive Care	100%	80%	100%
Outpatient Surgical / Hospital Facility	100%	80%	100%
Laboratory	100%	80%	100%
Radiology / X-ray	100%	80%	100%
Chemotherapy / Radiation Therapy	100%	80%	100%
Pre-admission Testing	100%	80%	100%
Surgery	100%	80%	100%
Reconstructive Surgery Surgery is incidental to or follows Surgery that was covered under the Plan	100%	80%	100%
Assistant Surgeon 20% of the primary surgeon’s eligible fee	100%	80%	100%
Anesthesia	100%	80%	100%
Durable Medical Equipment	100%	80%	100%
Chiropractic Care Medical order or Treatment plan required	100%	80%	100%
Physical Therapy Maximum Visits per Day: 1 Medical order or Treatment plan required	100%	80%	100%
Maternity and Newborn Care Maximum Limit: $5,000 Newborn routine care during the first 31 days of life	80%	60%	100%
Extended Care Facility Upon direct transfer from acute care Hospital	100%	80%	100%
Inpatient or Outpatient Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Benefit	In-Network	Out-of-Network	International
Home Nursing Care Provided by a Home Health Care Agency Upon direct transfer from an acute care Hospital	100%	80%	100%
Prescriptions Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Inpatient	100%	80%	100%
Outpatient	Not Applicable	50%	50%
Mental or Nervous / Substance Abuse Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Inpatient Mental or Nervous / Substance Abuse Maximum Limit: $10,000 Not covered if incurred at the Student Health Center	100%	80%	100%
Outpatient Mental or Nervous / Substance Abuse Maximum Limit per Day: $50 Maximum Limit: $500 Not covered if incurred at the Student Health Center	100%	80%	100%
Emergency Services NOT Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Emergency Local Ambulance Period of Coverage Limit per Injury: $750 Period of Coverage Limit per Illness $750 (resulting in an Inpatient Hospitalization)	100%	100%	100%
Emergency Medical Evacuation Maximum Limit: $500,000 Must be approved in advance and coordinated by the Company	100%	100%	100%
Emergency Reunion Maximum Limit: $50,000 Maximum Days: 15 Meal Maximum per Day: $25 Reasonable and necessary travel costs and accommodations Must be approved in advance by the Company	100%	100%	100%
Emergency Services NOT Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Benefit	In-Network	Out-of-Network	International
Interfacility Ambulance Transfer Services rendered in the United States Transfer must be a result of an Inpatient Hospitalization	100%	100%	Not Applicable
Political Evacuation and Repatriation Maximum Limit: $10,000 Must be approved in advance by the Company	100%	100%	100%
Return of Mortal Remains Maximum Limit: $50,000 Local Burial / Cremation at place of death Maximum Limit: $5,000 Return of Insured Person’s Mortal Remains to Country of Residence Must be approved in advance by the Company	100%	100%	100%
Other Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Accidental Death & Dismemberment Not subject to Deductible and Coinsurance Death must occur within 90 days of the Accident	Accidental Death Principal Sum: Insured Person Spouse Child		$25,000 $10,000 $5,000
	Accidental Dismemberment: Loss Sight of one eye One hand or one foot One hand and the loss of sight of one eye One foot and the loss of sight of one eye One hand and one foot Both hands or both feet Sight of both eyes		Percent of Principal Sum 50% 50% 100% 100% 100% 100% 100%
Dental Treatment Period of Coverage Limit: $350 (Treatment due to Unexpected pain to sound, natural teeth) Period of Coverage Limit per Injury: $500 (Non-emergency Treatment by a Dental Provider due to an Accident)	Not Applicable	80%	100%
Other Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Benefit	In-Network	Out-of-Network	International
Traumatic Dental Injury Treatment at a Hospital Facility due to an Accident Additional Treatment for the same Injury rendered by a Dental Provider will be paid at 100%	100%	80%	100%
Incidental Trip Maximum Days: 14 Insured Person’s Country of Residence is not the United States Refer to the INCIDENTAL TRIP provision for further details	100%	80%	100%
Intercollegiate, Interscholastic, Intramural, or Club Sports Period of Coverage Limit per Illness or Injury: $5,000	100%	80%	100%
Personal Liability Secondary to any other insurance No coverage for Injury to a related Third Party or damage to related Third Person’s property Refer to the PERSONAL LIABILITY provision for further details and requirements	Combined Maximum Limit: $10,000
	Injury to Third Person: Per Injury Deductible: $100 Damage to Third Person’s property: Per damage Deductible: $100
Terrorism Not subject to Deductible and Coinsurance Maximum Limit: $50,000	100%	100%	100%