Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: Lloyd's of London
| Overall Maximum Limit |
$200,000 (Excludes Emergency Medical Evacuation, Accidental Death and Dismemberment, Repatriation of Remains, and Emergency Reunion) |
| Maximum per Injury / Illness | $100,000 |
| Deductibles (except Emergency Room) |
$50 per injury or illness within the Preferred Provider Organization (PPO) or student health center; otherwise $150 per injury or Illness. If treatment received outside of U.S., $50 per illness or injury. |
| Emergency Room Deductible –Claims incurred in U.S. | $350 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: $50 maximum per day, $500 maximum. Inpatient: Usual, reasonable and customary charges up to $5,000. 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 | $250 |
| Therapeutic Termination of Pregnancy | $500 |
| Physical Therapy and Chiropractic Care |
$50 per visit per day Must be ordered in advance by a physician and not obtained at a student health center |
| 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 | |
| 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 |
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 - 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.