Plan Administrator: Tokio Marine HCC - Medical Insurance Services Group | AM Best Rating: A "Excellent" | Underwriter: Lloyd's
MEMBER ELIGIBILITY
ELIGIBILITY
1. You must be under age 65; and
a. A full-time student at a college or university (excluding online colleges and universities); or
b. Within 31 days of being a full-time student at a college or university; or
c. A student under age 19 enrolled in a secondary school; or
d. A full-time scholar affiliated with an educational institution and performing work or research for at least 30 hours per week; and
2. You must be residing outside your home country for the purpose of pursuing international educational activities; and
3. You must not have obtained residency status in your host country; and
4. If in the U.S., you must hold a valid education-related visa. A copy of the I-20 or DS2019 may be requested.
J-1 and F-1 visa holders: The full-time student/scholar status requirement is waived within the U.S.
if you have a valid F-1 visa (including OPT) or a J-1 visa. Full-time status requirements remain in force for individuals holding M-1, or other category visas.
CERTIFICATE EFFECTIVE & TERMINATION DATES
CERTIFICATE EFFECTIVE DATE
Insurance hereunder is effective on the later of:
1. The moment we receive an application and correct premium if the application and payment is made online or by fax;
2. 12:01am U.S. Eastern Time on the date we receive an application and correct premium if the application and payment is made by mail; The moment you depart from your home country;
or
3. 12:01am U.S. Eastern Time on the date requested on the application.
CERTIFICATE TERMINATION DATE
Insurance hereunder terminates on the earlier of:
1. 11:59pm U.S. Eastern Time on the last day of the period for which premium has been paid;
2. 11:59pm U.S. Eastern Time on the date requested on the application;
3. 12:01am U.S. Eastern Time on the date you no longer meet eligibility requirements; or
4. The moment of arrival upon your return to your home country (unless you have started a benefit period or are eligible for home country coverage).
DEFINITIONS
Accident means a sudden, unintentional and unexpected occurrence caused by external, visible means and resulting in physical injury to you. The cause or one of the causes of such accident is external to your own body and occurs beyond your control.
Accidental Death means a sudden, unintentional and unexpected occurrence caused solely by external, visible means resulting in physical injury to you and your subsequent death. Death must occur within 30 days of thE sudden, unintentional and unexpected occurrence and not be contributed to by illness or disease.
Accidental Dismemberment means a sudden, unintentional and unexpected occurrence caused solely by external, visible means and resulting in complete severance from the body of one or more limbs or eyes and not contributed to by illness or disease. For purposes of the Accidental Death and Dismemberment benefit, the term “limb” shall mean: the arm when the severance is at or above (toward the elbow) the wrist, or the leg when the severance is at or above (toward the knee) the ankle. Loss of eye(s) shall mean: complete, permanent, irrevocable loss of sight.
Acute Onset of Pain (Emergency Dental) means a sudden and unexpected occurrence of pain which occurs spontaneously and without advance warning, either in the form of physician or dentist recommendation or symptoms, including pain, which would have caused a prudent person to seek medical or dental attention prior to the onset of pain. Treatment must be obtained within 24 hours of the sudden and unexpected occurrence of pain.
Acute Onset of Pre-existing Condition means a sudden and unexpected outbreak or recurrence of a preexisting condition(s) which occurs spontaneously and without advance warning either in the form of physicianrecommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the certificate effective date. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A pre-existing condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset.
This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the certificate effective date.
Alcohol Abuse means any pattern of pathological use of alcohol that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.
Beneficiary means the individual named in your application to be the recipient of any Accidental Death or Common Carrier Accidental Death benefit. If you do not designate a beneficiary on the application, the beneficiary is automatically as follows:
Members age 18 or older: 1. Spouse (if any), 2. Children (if any) equally, 3. Your estate.
Members under age 18: 1. Custodial Parent(s) (if any), 2. Siblings (if any) equally, 3. Your estate.
Certificate means the document issued to you that provides evidence of benefits payable under the Master Policy.
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 newcertificate period will begin.
Coinsurance means your payment of eligible expenses at the percentage specified in the Schedule of Benefits and Limits.
Covered Pregnancy means a pregnancy which began after the effective date of coverage.
Custodial Care means that type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist you in performing the activities of daily living. Custodial care also includes nonacute care for the comatose, semi-comatose, paralyzed or mentally incompetent patients.
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.
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.
Dental Treatment means the care of teeth, gums or bones supporting the teeth, including dentures and preparation for dentures.
Drug Abuse means any pattern of pathological use of a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.
Durable Medical Equipment means a standard basic hospital bed and/or a standard basic wheelchair.
Educational or Rehabilitative Care means care for restoration (by education or training) of one’s ability to function in a normal or near normal manner following an illness or injury. This type of care includes, but is not limited to, vocational or occupational therapy and speech therapy.
Emergency means a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing your life or limb in danger if medical attention is not provided within 24 hours.
Express Kidnapping means the actual or attempted abduction and holding of you against your will where your personal belongings and/or readily available assets are surrendered by you in exchange for your release
Extended Care Facility means an institution, or a distinct part of an institution, which is licensed as a hospital, extended care facility or rehabilitation facility by the state in which it operates; and is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a physician and the direct supervision of a registered nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a physician; and provides each patient with active treatment of an illness or injury. Extended care facility does not include a facility primarily for rest, the aged, substance abuse treatment, custodial care, nursing care or for care of mental health disorders or the mentally incompetent.
Full-time Scholar means an individual who is affiliated with an educational institution and is engaging in educational activities for at least 30 hours per week. These activities may include but not be limited to performing research in an area of specialty or teaching for a temporary period of time.
Full-time Student means a student at a college or university who is taking 10 credit hours (undergraduate students) or 6 credit hours (graduate students). Full-time student status for individuals enrolled at colleges or universities that do not use a credit hour system must provide documentation of full-time student status.
Home Country means, for U.S. Citizens, the United States of America, regardless of the location of your principal residence. For non-U.S. Citizens, home country is the country where you principally reside and receive regular mail.
Home Health Care Agency means a public or private agency or one of its subdivisions, which operates pursuant to law and is regularly engaged in providing home nursing care under the supervision of a registered nurse, and maintains a daily record on each patient, and provides each patient with a planned program of observation and treatment by a physician.
Home Nursing Care means services provided by a home health care agency and supervised by a registered nurse, which are directed toward the personal care of a patient, provided always that such care is provided in lieu of medically necessary inpatient care in a hospital.
Hospital means an institution which operates as a hospital pursuant to law, and is licensed by the state or country in which it operates; and operates primarily for the reception, care and treatment of sick or injured persons as inpatients; and provides 24-hour nursing service by registered nurses on duty or call; and has a staff of one or more physicians available at all times; and provides organized facilities and equipment for diagnosis and treatment of acute medical conditions on its premises; and is not primarily a rehabilitation facility, long-term care facility, extended care facility, nursing, rest, custodial care or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment.
Host Country means the country, other than the home country, in which you will engage in educational pursuits. For legal residents and citizens of the U.S., the host country must be outside the U.S., including the U.S. Virgin Islands, Puerto Rico, Guam, American Samoa, and the Northern Mariana Islands.
Illness means a sickness, disorder, illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. Illness does not include learning disabilities, attitudinal disorders or disciplinary problems.
Injury means an unexpected and unforeseen harm to the body caused by an accident that requires medical treatment.
Inpatient means a person who is an overnight resident patient of a hospital, using and being charged for room and board, or a patient held for observation in a hospital for at least 12 hours.
Intensive Care Unit means a cardiac care unit or other unit or area of a hospital that meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.
Investigational, Experimental or for Research Purposes means procedures, services or supplies that are by nature or composition, or are used or applied, in a way which deviates from generally accepted standards of current medical practice.
Kidnapping means the actual, alleged, or attempted abduction and holding of you against your will by a person or persons who demand a ransom specifically from your assets in exchange for your release.
Medically Necessary means a service or supply which is necessary and appropriate for the diagnosis or treatment of an illness or injury based on generally accepted current medical practice as determined by us. A service or supply will not be considered medically necessary if is provided only as a convenience to you or the provider, and/or is not appropriate for your diagnosis or symptoms, and/or exceeds in scope, duration or intensity that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment of an illness or injury.
Member means an individual who is covered under this insurance.
Mental Health Disorder means a mental or emotional disease or disorder which generally denotes a disease of the brain with predominant behavioral symptoms; or a disease of the mind or personality, evidenced by abnormal behavior; or a disorder of conduct evidenced by socially deviant behavior. Mental health disorders include: psychosis, depression, schizophrenia, bipolar affective disorder, and those psychiatric illnesses listed in the current edition of the diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association.
Outpatient means a member who receives medically necessary treatment by a physician for injury or illness that does not require overnight stay in a hospital.
Personal Belongings means monies and/or property of monetary value that are:
1. Being carried or transported by you when an express kidnapping or kidnapping first occurs; and
2. Are surrendered during the course of an express kidnapping or kidnapping.
Physician means a Doctor of Medicine (MD), Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DDM), Doctor of Podiatry (DPM), Doctor of Osteopathy (DO), a licensed Physical Therapist or Physiotherapist, and a Doctor of Psychiatry (Psy.D) and a Doctor of Psychology (Ph.D.). Physician also includes a Certified Nurse Practitioner (CNP), Certified Registered Nurse Anesthetist (CRNA), Nurse Midwife or a Physician Assistant (PA) under the direction of a medical doctor. A physician must be currently licensed by the jurisdiction in which the services are provided, and the services must be within the scope of that license and covered under this Master Policy.
Ransom means monies and/or other consideration of monetary value that are surrendered or to be surrendered by you or on your behalf to meet an express kidnapping or kidnapping demand.
Related Third Person means your relative, your traveling companion, your traveling companion’s relative, and any other person, individual or family member with whom you are residing or being hosted.
Relative means biological or step parent current spouse, biological or stepsiblings, or child or stepchild, age 18 or older.
Routine Physical Exam means and examination of the physical body by a physician for preventative or informative purposes only, and not for the diagnosis or treatment of any condition. Routine physical exam also includes diagnostic labs, x-rays, and other procedures for screening, preventative, or informative purposes.
Sexually Transmitted Diseases means diseases including but not limited to syphilis, gonorrhea, chlamydiosis, trichomoniasis, genital herpes, and Human Papillomavirus (HPV).
Student Health Center means a medical facility of an educational institution that provides basic health services for students for a minimum of 10 hours per week during the school semester. Basic services must include staffing by a licensed medical provider (MD, CNP, or RN) for the purpose of assessment and treatment of minor illnesses and injuries and/or referral to another medical provider.
Substance Abuse means alcohol, drug or chemical abuse, overuse or dependency.
Surgery or Surgical Procedure means an invasive diagnostic procedure, or the treatment of illness or injury by manual or instrumental operations performed by a physician while the patient is under general or localanesthesia.
Therapeutic Termination of Pregnancy means willful termination of pregnancy determined to be medically necessary for the wellbeing of the mother.
Third Person means any individual, natural person, or other legal entity or person, other than you or a related third person.
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.
You/Your means each insured person named in the certificate.
We/Us/Our means Tokio Marine HCC Medical Insurance Services Group.