Study USA Preferred 500

Plan Detail

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

Benefits


Overall Maximum Limit $500,000
(Excludes Emergency Medical Evacuation, Accidental Death and Dismemberment, Repatriation of Remains, and Emergency Reunion)
Maximum per Injury / Illness $500,000
Deductibles (except Emergency Room) $25 per injury or illness within the Preferred Provider Organization (PPO) or student health center; otherwise $50 per injury or Illness.
If treatment received outside of U.S., $25 per illness or injury.
Emergency Room Deductible –Claims incurred in U.S. $100 for treatment received in an emergency room unless admitted as inpatient.
Coinsurance – Claims incurred in U.S. 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.
Outside the PPO, we will pay 70% of the next $25,000 of eligible expenses after the deductible, then 100% to the overall maximum limit.
Coinsurance – Claims incurred outside U.S. We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.
Benefit Limit
Subject to deductible, coinsurance, and per certificate period unless specifically indicated otherwise
Hospital Room and Board Average semi-private room rate, including nursing services
Intensive Care Unit Usual, reasonable and customary charges
Local Ambulance $350 per injury or illness, when covered illness or injury results in hospitalization as inpatient.
Outpatient Treatment Usual, reasonable and customary charges
Outpatient Prescription Drugs $10 copay for generic drugs
$20 copay for brand name
Mental Health Disorders (includes drug abuse and alcohol abuse) Outpatient: Within the PPO, we will pay 80% of eligible expenses up to the overall maximum or 60% outside the PPO. Maximum of 30 visits.
Inpatient: Within the PPO, we will pay 80% of eligible expenses up to the overall maximum or 60% outside the PPO. Maximum of 30 days.
Treatment must not be provided at a student health center.
Maternity Care for a Covered Pregnancy We will pay 80% of eligible expenses up to the overall maximum or 70% outside the PPO.
Nursery Care of Newborn $750
Therapeutic Termination of Pregnancy $500
Physical Therapy and Chiropractic Care $75 per visit per day
Must be ordered in advance by a physician and not obtained at a student health center
Dental Treatment due to Accident $1,000 maximum per certificate period
Wellness 100% of one routine physical exam per member
Intercollegiate, Interscholastic, Intramural, or Club Sports $5,000 maximum per injury or illness, medical expenses only
Terrorism $50,000 lifetime maximum, eligible medical expenses only.
All Other Eligible Medical Expenses Usual, reasonable and customary charges
Benefit Limit
Not Subject to Deductible or Coinsurance
Dental Treatment to alleviate pain $100
Emergency Medical Evacuation $500,000 lifetime maximum
Repatriation of Remains $25,000 lifetime maximum
Emergency Reunion $5,000, subject to a maximum of 15 days
Accidental Death & Dismemberment Lifetime Maximum - $25,000
Death - $25,000
Loss of 2 Limbs - $25,000
Loss of 1 Limb - $12,500
Personal Liability $250,000 lifetime maximum
$250,000 third person injury
$250,000 third person property
$2,500 related third person property

Member Eligibility, Certificate Effective & Termination Dates, Benefit Period, and Home Country Coverage

Eligibility

A. Participant

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 5 Study USA Preferred 500 - Description of Coverage | Tokio Marine HCC - MIS Group

force for individuals holding M-1, or other category visas.

B. Dependents

1. You be the participant’s legally married spouse, or must be the participant’s unmarried child under age 19 years and chiefly dependent on the participant for support and maintenance; and

2. You must accompany the participant abroad on a similar visa or passport while the participant engages in international educational activities; and

3. You must be temporarily located outside the participant’s home country; and

4. You must not have obtained residency status in the host country.

C. Special Conditions for Newborn or Adopted Children:

1. Newborn or adopted children will be automatically covered as dependents for the first 31 days of life provided that the delivery is covered by this insurance or placement occurs while the participant’s coverage is in effect. If the delivery of the newborn is not covered under this insurance, the newborn is eligible for coverage beginning at 14 days of age.

2. Newborn and adopted children must be enrolled within the first 31 days after birth for newborns or within 31 days of placement for adoptions. Enrollment requires written notification of the new dependent’s name, birth date, gender, and citizenship as well as payment of any additional premium due.

3. If a newborn or adopted child is not enrolled by the 31st day following birth (for newborns) or placement (for adopted children), then coverage terminates on the 31st day.

Certificate Effective Date

Insurance hereunder is effective on the later of:

1. The moment we receive application and correct premium if application and payment is made online or by fax; or

2. 12:01am U.S .Eastern Time on the date we receive application and correct premium if application and payment is made by mail; or

3. The moment you depart from your home country; or

4. 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; or

2. 11:59pm U.S. Eastern Time on the date requested on the application; or

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).

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.

Home Country Coverage

Benefit Period – 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.6 Study USA Preferred 500 - Description of Coverage | Tokio Marine HCC - MIS Group

Incidental Home Country Coverage –For every three month period during which you are covered, eligible medical expenses are covered up to a maximum of 15 days for any three month period. 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.