StudentSecure - Budget Including USA

Plan Detail

Plan Administrator: Tokio Marine HCC - Medical Insurance Services Group | AM Best Rating: A "Excellent" | Underwriter: Lloyd's

Benefits


SCHEDULE OF BENEFITS AND LIMITS

Overall Maximum Limit

$500,000

Maximum per Injury / Illness

$250,000

Deductibles (except Emergency Room)

$45 per injury or illness within the Preferred Provider Organization

(PPO) network or student health center; otherwise $90 per injury or Illness.

If treatment received outside of U.S., $45 per illness or injury

Emergency Room Deductible (claims incurred in U.S. only)

$350 for treatment received in an emergency room

Coinsurance - Claims Incurred in U.S.

 

In-Network Payment

Within the PPO: We will pay 80% of the next $25,000 of eligible expenses, after the deductible, then 100% to the overall maximum limit.

Out-Of-Network Payment

Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount

Coinsurance - Claims Incurred outside U.S.

We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.

Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise.

Benefit

Limit

Hospital Room and Board

Average semi-private room rate, including nursing services

Intensive Care Unit

Up to the overall maximum limit

Local Ambulance

Up to $500 per injury or illness, when covered illness or injury results in hospitalization as inpatient. - not subject to coinsurance

Outpatient Treatment

Up to the overall maximum limit

Outpatient Prescription Drugs

50% of actual charges - not subject to deductible or coinsurance

Outpatient Physical Therapy & Chiropractic Care

Up to $50 per visit per day - not subject to coinsurance

Must be ordered in advance by a physician and not obtained at a student health center

Intercollegiate, Interscholastic,

Intramural, or Club Sports

Up to $3,000 maximum per injury or illness, medical expenses only

Mental Health Disorders (Includes drug abuse and alcohol abuse)

Treatment must not be provided at a student health center.

Outpatient: Maximum of 30 visits.

Inpatient: Maximum of 30 days.

Maternity Care for a Covered Pregnancy

Up to $5,000.

Nursery Care of Newborn

Up to $250 - not subject to coinsurance

Therapeutic Termination of Pregnancy

Up to $500 - not subject to coinsurance

Dental Treatment due to Accident

Up to $250 maximum per tooth; $500 maximum per certificate period - not subject to coinsurance

Emergency Dental (Acute Onset of Pain)

Up to $100 - not subject to deductible or coinsurance

Acute Onset of Pre-existing Condition

(Excludes chronic and congenital conditions)

Up to $25,000 lifetime maximum for eligible medical expenses

Terrorism

Up to $50,000 lifetime maximum, eligible medical expenses only

All Other Eligible Medical Expenses

Up to the overall maximum limit

Emergency Travel Benefits

Limit

Emergency Medical Evacuation

Up to $250,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Repatriation of Remains

Up to $25,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Emergency Reunion

Up to $1,000, subject to a maximum of 15 days - not subject to deductible, coinsurance, or overall maximum limit

Certificate Period means the period of time beginning on the date and time of the certificate effective date and ending on the date and time of the certificate termination date, up to 364 days, after which a new certificate period will begin.

Coinsurance means your payment of eligible expenses at the percentage specified in the Schedule of Benefits and Limits.

Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and Limits that you must pay per certificate period before eligible expenses are paid.

Usual, Reasonable and Customary means the lesser of the following:

1. One and a half times (150%) of the charges payable under the United States Medicare program, for claims incurred outside the PPO network within the U.S., or

2. Most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. What is defined as usual, reasonable and customary charges will be determined by us. In determining whether a charge is usual, reasonable and customary, we may consider one or more of the following factors: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the severity or nature of the illness or injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; such other factors we, in the reasonable exercise of discretion, determine are appropriate.

BENEFIT PERIOD & HOME COUNTRY COVERAGE

BENEFIT PERIOD

While the certificate is in effect, the benefit period does not apply. Upon termination of the certificate, in accordance with this provision, we will pay eligible medical expenses for up to 60 days beginning on the first day of diagnosis or treatment of a covered injury or illness while you are outside your home country and while this certificate is in effect. The benefit period applies only to eligible medical expenses related to a condition for which you are hospitalized as an inpatient on the termination date of the certificate.

In the event you begin a benefit period while the certificate is in effect, and the certificate terminates because you return to your home country, we will pay eligible medical expenses which are incurred in your home country during the benefit period. Home country coverage applies only to eligible medical expenses for which you are hospitalized as an inpatient on the termination date of the certificate.

INCIDENTAL HOME COUNTRY COVERAGE

For every three-month period during which you are covered, you are eligible for up to a maximum of 15 days of coverage in your home country for eligible medical expenses. Any benefit accrued under a single three-month period does not accumulate to another period. Failure to continue your international trip or your return to your home country for the sole purpose of obtaining treatment for an illness or injury that began while traveling shall void any home country coverage provided under the terms of this agreement.

For all non-U.S. citizens electing coverage “Excluding the U.S.” and for all U.S. citizens or residents, no coverage is provided within the U.S., except for U.S. citizens or residents during an eligible incidental home country visit or an eligible benefit period.

Except for a benefit period, coverage provided under this Master Policy is for a maximum duration of 364 days. Any extension is based upon the eligibility rules in force and is solely at our discretion.

Notwithstanding the foregoing, coverage under all plans shall terminate on the date we, at our sole option, elect to cancel all members of the same sex, age, class or geographic location, provided we give no less than 30 days advance written notice by mail to your last known address.

MEDICAL & REPATRIATION EXPENSES

Subject to the limits set forth in the Schedule of Benefits and Limits, and subject to the conditions and restrictions contained in this provision, we will pay the following expenses incurred while this insurance is in effect.

MEDICAL EXPENSES

YOU ARE COVERED:

1. Charges made by a hospital for:

a. Daily room and board and nursing services not to exceed the average semi-private room rate; and

b. Daily room and board and nursing services in Intensive Care Unit; and

c. Use of operating, treatment or recovery room; and

d. Services and supplies which are routinely provided by the hospital to persons for use while inpatients; and

e. Emergency treatment of an injury or illness, even if hospital confinement is not required.

However, charges for use of the emergency room itself within the U.S. will be subject to deductible as provided under the Schedule of Benefits and Limits.

2. Surgery at an outpatient surgical facility, including services and supplies.

3. Charges made by a physician for professional services, including surgery. Charges for an assistant surgeon are covered up to 20% of the usual, reasonable and customary charge of the primary surgeon, but standby availability will not be deemed to be a professional service and therefore is not covered hereunder.

4. Dressings, sutures, casts or other supplies which are medically necessary and administered by or under the supervision of a physician, but excluding nebulizers, oxygen tanks, diabetic supplies, supplies that are available over the counter or without prescriptions, and support or brace appliances.

5. Diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, intelligence, behavioral and educational testing are not included).

6. Artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the replacement or repair thereof.

7. Reconstructive surgery when the surgery is directly related to surgery which is covered hereunder.

8. For radiation therapy or treatment and chemotherapy.

9. Hemodialysis and the charges by the hospital for processing and administration of blood or blood components but not the cost of the actual blood or blood components.

10. Oxygen and other gasses and their administration by or under the supervision of a physician.

11. Anesthetics and their administration by a physician.

12. Drugs which require prescription by a physician for treatment of a covered injury or illness, but excluding drugs: prescribed for the treatment of diabetes, replacement of lost, stolen, damaged, expired or otherwise compromised drugs.

13. Care in a licensed extended care facility upon direct transfer from an acute care hospital.

14. Home nursing care in bed by a qualified licensed professional, provided by a home health care agency upon direct transfer from an acute care hospital and only in lieu of medically necessary inpatient hospitalization.

15. Emergency local ambulance transport necessarily incurred in connection with injury or illness resulting in inpatient hospitalization.

16. Emergency dental treatment and dental surgery necessary to restore or replace sound natural teeth lost or damaged in an accident which was covered under this insurance.

17. Emergency dental treatment necessary to resolve acute onset of pain, provided treatment is obtained within 24 hours of the acute onset of pain.

18. Medically necessary rental of durable medical equipment (consisting of a standard basic hospital bed and or a standard basic wheelchair) up to the purchase prices.

19. Outpatient physical therapy if prescribed by a physician for treatment of a covered injury or illness.

20. Routine and medically necessary care of newborns as provided in the Schedule of Benefits, provided that the delivery of the newborn is covered hereunder.

21. Pre-natal care, delivery of newborn, and post-natal care related to a covered pregnancy which began after the effective date of coverage.

22. For treatment of mental health disorders including drug abuse and alcohol abuse.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

EMERGENCY MEDICAL EVACUATION

YOU ARE COVERED:

1. Emergency air transportation to a suitable airport nearest to the hospital where you will receive treatment; and

2. Emergency ground transportation necessarily preceding emergency air transportation; and from the destination airport to the hospital where you will receive treatment.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The evacuation is recommended by the attending physician who certifies that it is medically necessary and that transportation by any other method would result in the loss of your life or limb; and

2. The evacuation is agreed upon by you or your relative; and

3. Travel arrangements, excluding Emergency Local Ambulance, are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. The illness or injury giving rise to the expense is not covered under this insurance; or

2. Medically necessary treatment, services and supplies can be provided locally; or

3. If transportation by any other method would not result in the loss of your life or limb; or

4. The condition giving rise to the Emergency Medical Evacuation did not occur spontaneously and without advance warning, either in the form of physician recommendation or symptoms which would have caused a prudent person to seek medical attention prior to the onset of the emergency; or

5. Expenses are directly or indirectly from anything in the General Exclusions.

We will provide Emergency Medical Evacuation only to the nearest hospital that is qualified to provide the medically necessary treatment, services and supplies to prevent your loss of life or limb.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

Notwithstanding the foregoing, and if you are visiting the U.S., we will pay for expenses to return you to your home country if the attending physician and our medical consultant agree that transfer to the home country is more appropriate than transfer to the nearest qualified hospital.

REPATRIATION OF REMAINS

YOU ARE COVERED:

1. Air or ground transportation of bodily remains or ashes to the airport or ground transportation terminal nearest your principal residence; and

2. Reasonable costs of preparation of the remains necessary for transportation.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The illness or injury giving rise to the expense are covered under this insurance; and

2. Travel arrangements are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

We are held harmless and shall not be held liable for loss of or any damage or other impairment to bodily remains incurred during the repatriation process or otherwise.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

EMERGENCY REUNION

YOU ARE COVERED:

1. The cost of an economy round-trip air or ground transportation ticket for one relative for transportation to the terminal serving the area where you are hospitalized or are to be hospitalized following Emergency Medical Evacuation; and

2. Reasonable expenses for lodging and meals for the relative, which are incurred in the area where you are hospitalized for a period not to exceed 15 days.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You have a covered Emergency Medical Evacuation; or

2. You are hospitalized as an inpatient for at least five days due to a life-threatening covered condition. Emergency Reunion benefits not related to an Emergency Medical Evacuation will be paid only following the end of the minimum five day inpatient stay.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

SPORTS AND ACTIVITIES

A. INTERCOLLEGIATE, INTERSCHOLASTIC, INTRAMURAL, OR CLUB SPORTS

YOU ARE COVERED:

1. Subject to the limit set forth in the Schedule of Benefits and Limits, you are covered for a new injury or illness sustained while covered under this policy and  taking part in sanctioned intercollegiate, interscholastic, intramural, or club sports.

YOU ARE NOT COVERED IF:

1. The sports or athletics are not sanctioned by your school; or

2. The activity is performed in a professional capacity or for any wage, reward, or profit; or

3. The injury or illness is sustained while you are not actively covered hereunder; or

4. Expenses arise directly or indirectly from anything mentioned in the General Exclusions.

B. LEISURE, RECREATIONAL, ENTERTAINMENT, OR FITNESS SPORTS AND ACTIVITIES

YOU ARE COVERED:

1. Subject to the overall maximum limit, you are covered for injury or illness sustained while taking part in sports and activities, unless it is excluded below. You must ensure the activity is adequately supervised and that appropriate safety equipment  (such as protective headwear, life jackets etc.) are worn at all times.

YOU ARE NOT COVERED IF:

1. The sports or athletics involve regular or scheduled practice and/or games; or

2. The activity is performed in a professional capacity or for any wage, reward, or profit; or

3. Expenses arise directly or indirectly from anything mentioned in the General Exclusions; or

4. Any of the excluded items listed below:

TERRORISM

YOU ARE COVERED:

1. Eligible Medical Expenses for treatment of injuries and illnesses resulting from an Act of Terrorism, up to the limit set forth in the Schedule of Benefits and Limits, provided all of the following conditions are met.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The injury or illness does not result from the use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon;

2. You have no direct or indirect involvement in the Act of Terrorism;

3. The Act of Terrorism is not in a country or location where the U.S. Department of State has issued a level 3 or level 4 travel advisory that has been in effect within the 6 months immediately prior to your date of arrival; and

4. You have not failed to depart a country or location within 10 days following the date a level 3 or level 4 travel advisory for that country or location is issued by the United States government.

YOU ARE NOT COVERED IF:

1. Loss, damage, cost or expense directly or indirectly caused by, resulting from or in connection with any ofthe following regardless of any other cause or event contributing concurrently or in any other sequence to the loss, damage, cost or expense:

a. War, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power;

b. The use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon; however, this exclusion shall not apply where you are exposed to nuclear radioactive and/or radioactive material for the purpose of medical treatment;

c. Any Act of Terrorism, not specifically covered above;

d. Coverage for loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to (a), (b) or (c) above; and

e. Expenses arise directly or indirectly from anything mentioned in the General Exclusions.

For the purpose of this insurance, an “Act of Terrorism” means an act, including but not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.

If  we allege that by reason of this exclusion, any loss, damage, cost or expense is not covered by this insurance, the burden of proving the contrary shall be upon you.

In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.

Cyber means the use or operations, as a means for inflicting harm, of any computer, computer software program, malicious code, computer virus or process or any other electronic system.