Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: Lloyd's of London
This insurance is not subject to, and does not provide some of the insurance benefits required by, the United States PPACA. In no event will we provide benefits in excess of those specified in the certificate documents, and this insurance is not subject to guaranteed issuance or renewal. PPACA requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage. In certain circumstances penalties may be imposed on U.S. residents and citizens who do not maintain PPACA compliant insurance coverage. You should consult your attorney or tax professional to determine if PPACA’s requirements are applicable to you. The certificate contains the plan benefits, including a lifetime maximum that you have selected. Please review your choices to ensure that you have sufficient coverage to meet your medical needs.
This Description of Coverage is a summary of the provisions contained in Master Policy No.161920-SUSA. For a complete copy of the Master Policy, please contact Tokio Marine HCC Medical Insurance Services Group.
This Description is to help you understand the insurance that your certificate provides. It details the key features, benefits, limitations, exclusions, definitions, Schedule of Benefits and Limits, and any endorsements, applying to your certificate.
The levels of coverage which apply to your coverage are detailed in the Schedule of Benefits and Limits.
Complaints
This insurance policy has in it a Complaints Procedure which tells you what steps you can take if you wish to make a complaint.
Data Protection
We respect individual privacy and value your confidence. We restrict access to personal information to employees/partners who need to know that information in order to perform their jobs. Any employee that we determine is in violation of this policy will be subject to disciplinary action, up to and including termination and criminal prosecution.
We will not disclose your personal information to third parties outside Tokio Marine HCC and our partners unless ordered to do so to comply with the law of the countries in which we do business or when complying with the legal process.
Rights of Third Parties
You may assign benefits under this insurance to a hospital, physician or other provider. Any assignment shall not confer upon such hospital, physician or other provider, any right or privilege granted to you under this insurance except for the right to receive benefits, if any, which are determined to be due and payable hereunder. No hospital, physician or other provider shall have any direct or indirect claim or right of action against us.
Law and Jurisdiction
No action of law or equity may be brought to recover benefits under this insurance until 60 days after written proof of claim has been provided to us. No such action may be brought after the end of three (3) years after the time written proof of claim is required to be furnished. The validity, interpretation, and performance of this agreement shall be governed by and construed in accordance with the laws of Bermuda.
Tokio Marine HCC Medical Insurance Services Group (“MIS Group”)
A subsidiary of Tokio Marine HCC, HCC Lloyd’s Syndicate 4141 is managed by HCC Underwriting Agency Ltd which is authorized by the Prudential Regulation Authority (PRA) and regulated by the Financial Conduct Authority (FCA) and the Prudential Regulation Authority. Registered in England and Wales No. 04632146. Registered office: 1 Aldgate, London EC3N 1RE, United Kingdom.
These details can be checked on the Financial Services Register by visiting: www.fca.org.uk or contacting the Financial Conduct Authority on 0800 111 6768.
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
We will pay
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. 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.
We will not pay for claims arising directly or indirectly from
1. Anything mentioned in the General Exclusions.
Emergency Medical Evacuation
We will pay
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.
We will provide the above benefits only when the conditions and restrictions in this policy and the following are met, and
a. The illness or injury giving rise to the expense are covered under this insurance; and
b. Medically necessary treatment, services and supplies cannot be provided locally; and
c. Transportation by any other method would result in the loss of your life or limb; and
d. Recommended by the attending physician who certifies to the above; and
e. Agreed upon by you or your relative; and
f. The condition giving rise to the Emergency Medical Evacuation occurred 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.
We will not pay for claims arising directly or indirectly from
1. Travel arrangements, excluding Emergency Local Ambulance, that are not approved in advance and coordinated by us; and
2. Anything mentioned 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
We will pay:
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.
We will provide the above benefits only when the conditions and restrictions in this policy and the following are met, and
a. When the illness or injury giving rise to the expense are covered under this insurance.
We will not pay for claims arising directly or indirectly from
1. Travel arrangements that are not approved in advance and coordinated by us; and
2. Anything mentioned 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. You agree to hold us harmless and we shall not be held liable for any delays that are not within our direct and immediate control.
Emergency Reunion
We will pay:
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.
We will provide the above benefits only when the conditions and restrictions in this policy and the following are met, and
a. Only following a covered Emergency Medical Evacuation, or
b. 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.
We will not pay for claims arising directly or indirectly from
1. Anything mentioned in the General Exclusions.
A. Intercollegiate, Interscholastic, Intramural, or Club Sports
We will pay:
1. Subject to the limit set forth in the Schedule of Benefits and Limits, you are covered for injury or illness sustained while taking part in the following sanctioned intercollegiate, interscholastic, intramural, or club sports.
We will not pay for claims arising directly or indirectly from:
1. Sports or athletics not sanctioned by your school; and
2. Any activity performed in a professional capacity or for any wage, reward, or profit; and
3. Anything mentioned in the General Exclusions.
B. Leisure, Recreational, Entertainement or Fitness Sports and Activities
We will pay:
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.
We will not pay for claims arising directly or indirectly from:
1. Sports or athletics involving regular or scheduled practice and/or games; and
2. Any activity performed in a professional capacity or for any wage, reward, or profit; and
3. Anything mentioned in the General Exclusions; and
4. Any of the excluded items listed below:
• Aviation (except when traveling solely as a passenger in a commercial aircraft)
• Base Jumping
• BMX freestyle
• Bungee Jumping
• Free-Diving
• Hang-Gliding
• Jet Skiing
• Mountaineering where a reasonably prudent person would use ropes or guides or at elevations of 4,500 meters or higher
• Parachuting
• Racing by any Animal, Motorized Vehicle, or BMX
• Skateboarding
• Sky Diving
• Sky Surfing
• Snow Skiing and Snowboarding, except recreational downhill and/or cross country snow skiing or snowboarding (no cover provided while skiing away from prepared and marked in-bound territories and/or against the advice of the local ski school or local authoritative body)
• Spelunking
• Sub Aqua Pursuits involving underwater breathing apparatus unless accompanied by a certified instructor at depths less than 10 meters, or PADI/NAUI certified
• Surfing
• Whitewater Kayaking and Rafting
We will pay:
1. Death – we will pay the amount indicated in the Schedule of Benefits to the beneficiary.
2. Loss of 2 or more Limbs or eyes – we will pay the amount indicated in the Schedule of Benefits to you.
3. Loss of 1 Limb or eye – we will pay one-half of the amount indicated in the Schedule of Benefits to you.
We will provide the above benefits only when the conditions and restrictions in this policy and the following are met, and
a. Death must occur within 30 days of the sudden, unintentional and unexpected occurrence and not be contributed to by illness or disease; and
b. In no event will our payment under this benefit total more than the principal sum.
We will not pay for claims arising directly or indirectly from
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. Anything mentioned 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.
We will pay:
Up to the sum insured shown in the Schedule of Benefits and Limits (inclusive of legal costs and expenses) if you become legally liable to pay damages in respect of:
1. Accidental bodily injury, including death, illness and disease to a third person; and/or
2. Accidental loss of or damage to a third person’s material property (property that is both material and tangible); and/or
3. Accidental loss of or damage to a related third person’s material property (property that is both material and tangible);
We will not pay for claims arising directly or indirectly from
1. Intentionally committed acts, or arising from the influence of alcohol or drugs not medically prescribed by a licensed physician;
2. Bodily injury, illness or disease of any person under a contract of employment, service or apprenticeship with you when the bodily injury, illness or disease arises out of and in the course of their employment to you, or in connection with any trade, business or profession;
3. Loss or damage to property belonging to or held in trust by or in the custody or control of you other than temporary accommodation occupied by you in the course of the trip;
4. Bodily injury or damage caused directly or indirectly in connection with the ownership, possession or use by you or on behalf of you of: aircraft, hovercraft, watercraft, motorized vehicles, parachute, parasail, glider, firearms, fireworks, explosives, deadly weapons, or any racing activity;
5. Any damages, losses or claims caused in whole or in part by you during any hunt or as a result of hunting;
6. Bodily injury caused directly or indirectly in connection with the ownership, possession or occupation of land or buildings, immobile property or caravans or trailers;
7. Damages resulting from any fire, flood, wind, hail, waterleak, gas leak, explosion or other catastrophe;
8. Fraudulent, dishonest or criminal acts of you or any person authorised by you;
9. The consequences of any breach, violation or failure to perform any contractual undertakings or obligations, whether verbal or in writing;
10. Punitive or exemplary damages, or fines, penalties, assessments or claims by any governmental authorities or regulatory bodies;
11. Gambling, gaming, or betting of any kind;
12. Animals or pets belonging to you, or in your care, custody or control;
13. Anything mentioned in the General Exclusions.
Specific Conditions
1. You or your legal representatives will give us written notice immediately if you have received notice of any prosecution or inquest in connection with any circumstances which may give rise to liability under this section.
2. No admission, offer, promise, payment or indemnity shall be made by or on behalf of you without our prior written consent.
3. Every claim notice, letter, writ or process or other document served on you shall be forwarded to us and immediately upon receipt.
4. We shall be entitled to take over and conduct in your name the defense or settlement of any claim or to prosecute in your name for our own benefit any claim for indemnity or damages against all other parties or persons.
5. We may at any time pay you in connection with any claim or series of claims the sum insured (after deduction of any sums already paid as compensation) or any lesser amount for which such claim(s) can be settled. Once this payment is made we shall relinquish the conduct and control and be under no further liability in connection with such claim(s) except for the payment of costs and expenses recoverable or incurred prior to the date of such payment.
6. We will consider paying or advancing, but without any obligation or contractual duty to do so, up to $2,500 to you or for your benefit to settle and compromise an asserted claim against you so long as:
a. The asserted claim is one that may be eligible for coverage under this insurance;
b. A lawsuit has not yet been filed, or, if already filed, no response has been filed;
c. You obtain a full written release and/or covenant-not-to-sue satisfactory to us; and
d. A full proof of claim and other necessary documentation is satisfactorily provided to us.
Third Person means any individual, natural person, or other legal entity or person, other than you or a related third person.
Related Third Person means any individual or natural person who is your relative, your traveling companion a relative of such traveling companion, and any other person, individual or family member with whom you are residing or being hosted.
We will pay:
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.
We will provide the above benefits only when the conditions and restrictions in this policy and the following are met, and
a. The injury or illness does not result from the use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon; and
b. You have no direct or indirect involvement in the Act of Terrorism; and
c. The Act of Terrorism is not in a country or location where the United States government has issued a travel warning that has been in effect within the 6 months immediately prior to your date of arrival; and
d. You have not failed to depart a country or location within 10 days following the date a warning to leave that country or location is issued by the United States government.
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.
We will not pay for claims arising from
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; and
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; and
c. any Act of Terrorism, not specifically covered above; and
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. Anything mentioned in the General Exclusions.
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.
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.
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.
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.
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.
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 non-acute care for the comatose, semi-comatose, paralyzed or mentally incompetent patients.
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.
Dependent means the participant’s legally married spouse, or the participant’s unmarried child under age 19 years and chiefly dependent on the participant for support and maintenance, who is enrolled for coverage under this plan.
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.
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.
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.
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.
Participant means the full-time student or full-time scholar who is pursuing international educational activities outside of his/her home country and who is enrolled for coverage under this plan.
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.
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 syphilis, gonorrhea, lymphogranuloma venereum, chancroid, granuloma inguinale, chlamydiosis, trichomoniasis, genital candidiasis, genital herpes, Pelvic Inflammatory Disease (PID), Human Papillomavirus (HPV), mycoplasma genitalium, and viral hepatitis.
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 local anesthesia.
Therapeutic Termination of Pregnancy means willful termination of pregnancy determined to be medically necessary for the wellbeing of the mother.
Usual, Reasonable and Customary means the 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.