Study USA Healthcare - Platinum

Plan Detail

Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: Lloyd's of London

Benefits


SCHEDULE OF BENEFITS AND LIMITS

Plan Details

 

Overall Maximum Limit

$3,000,000

Maximum per Injury / Illness

$500,000

Deductibles (except Emergency Room)

$25 per injury or illness within the Preferred Provider Organization (PPO) network or student health center; otherwise $100 per injury or Illness. If treatment received outside of U.S., $25 per illness or injury

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

$100 for treatment received in an emergency room unless admitted as inpatient

Coinsurance - Claims Incurred in the U.S.

 

In-Network Payment

Within the PPO: We will pay 85% of the next $10,000 of eligible expenses, after the deductible, then 100% up 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 the U.S.

We will pay 100% of eligible expenses, after the deductible, up to the overall maximum 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 $350 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

Generic Drugs: $15 deductible per prescription Brand Name Drugs: $30 deductible per prescription

Outpatient Physical Therapy & Chiropractic Care

Up to $75 per visit per day - not subject to coinsurance Must be ordered in advance by a physician and not obtained at a student health center

Optional Intercollegiate, Interscholastic, Intramural, or Club Sports Rider

Up to $10,000 maximum per injury or illness, medical expenses only.

Sports & Activities - Leisure, Recreational, Entertainment, or Fitness

Up to the overall maximum limit

Mental Health Disorders (excludes drug abuse and alcohol abuse)

We will pay: Within the PPO: 80% of eligible expenses, after the deductible, up to the overall maximum. Outside the PPO: Usual, reasonable, and customary up to the overall maximum. You may be responsible for any charges exceeding the payable amount. Outside the U.S.: 100% coinsurance, after the deductible, up to the overall maximum. Outpatient: Maximum of 30 visits. Inpatient: Maximum of 30 days. Treatment must not be provided at a student health center.

Maternity Care for a Covered Pregnancy

We will pay: Within the PPO: 80% of eligible expenses, after the deductible, up to $8,000. Outside the PPO: Usual, reasonable, and customary up to $8,000. You may be responsible for any charges exceeding the payable amount. Outside the U.S.: 100% coinsurance, after the deductible, up to $8,000.

Nursery Care of Newborn

Up to $750 - not subject to coinsurance

Therapeutic Termination of Pregnancy

Up to $500 - not subject to coinsurance

Dental Treatment due to Accident

Up to $1,000 maximum per certificate period - not subject to coinsurance

Emergency Dental (Acute Onset of Pain)

Up to $100 - not subject to deductible or coinsurance

Wellness

100% of one routine physical exam per member

Optional Vaccination Benefit Rider

Up to $150. Covered vaccinations and testing are: Measles, Mumps, Rubella (MMR); Tetanus/Diphtheria/Pertussis (TDAP); Chicken Pox (Varicella); Hepatitis B; and Meningitis (Meningococcal MCV4 and B) - not subject to deductible or coinsurance

All Other Eligible Medical Expenses

Up to the overall maximum limit

Terrorism

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

Emergency Travel Benefits

Limit

Emergency Medical Evacuation

Up to $500,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Repatriation of Remains

Up to $50,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Emergency Reunion

Up to $5,000, subject to a maximum of 15 days - not subject to deductible, coinsurance, or overall maximum limit

Accidental Death & Dismemberment

Lifetime Maximum - $25,000 Death - $25,000 Loss of 2 Limbs - $25,000 Loss of 1 Limb - $12,500 - not subject to deductible, coinsurance, or overall maximum limit

Personal Liability

Up to $150,000 lifetime maximum Up to $150,000 third person injury Up to $150,000 third person property $1,500 related third person property - 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.

Coinsurance means your payment of eligible expenses as 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.

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. 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.

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

18. For treatment of mental health disorders.

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 your 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.

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

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.

2. 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 sports or athletics are intercollegiate, interscholastic, intramural, or club sports; or

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

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

5. Any of the excluded items listed below:

6. Aviation (except when traveling solely as a passenger in a commercial aircraft

TERRORISM

Charges resulting directly or indirectly from any Act of Terrorism are excluded under this insurance.

YOU ARE NOT COVERED FOR:

1. Loss, damage, cost or expense directly or indirectly caused by, resulting from or in connection with any of the 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; or 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.

ACCIDENTAL DEATH AND DISMEMBERMENT

YOU ARE COVERED:

1. Death – we will pay the amount indicated in the Schedule of Benefits to the beneficiary; or

2. Loss of 2 or more Limbs or eyes – we will pay you the amount indicated in the Schedule of Benefits; or

3. Loss of 1 Limb or eye – we will pay you one-half of the amount indicated in the Schedule of Benefits.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The accident giving rise to the Accidental Death or Dismemberment must be covered under this insurance; and

2. Death must occur within 30 days of the sudden, unintentional and unexpected occurrence and not be contributed to by illness or disease.

YOU ARE NOT COVERED IF:

1. Accidents or loss caused by or contributed to by any of the following:

a. Terrorism, war or act of war, whether declared or undeclared.

b. Your participation in a riot, insurrection or violent disorder.

c. Your service in the armed forces of any country.

d. Suicide or attempted suicide or self-inflicted injury, while sane or insane.

e. The voluntary use of any chemical compound, poison or drug, unless used according to the directions of a physician.

f. Committing or attempting to commit a felony.

g. Sickness, mental health disorder, or pregnancy.

h. As the result of intoxication as defined by the laws of the jurisdiction in which the accident occurred, whether directly or indirectly,

i. Myocardial infarction or cerebrovascular accident (CVA / Stroke).

j. Infection, except infection through a wound caused solely by an accident.

k. Injury while riding, boarding, or alighting from an aircraft if you were operating the aircraft, learning to operate the aircraft, serving as a member of the aircraft crew, or if the aircraft was being used for any purpose other than passenger transportation.

l. Medical or surgical treatment for any of the above.

m. Any non-covered sports activities.

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

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.

Beneficiary means the individual named in your application to be the recipient of any accidental death benefit.