New Higher Limit of $50K for Pre-existing Conditions, Effective May 1, 2010

FAQ on Main Program  **     FAQ on Pre-existing Condition Rider  * How Program Works?

Summary of Benefits Brochure 2009-2010 (PDF format)

SUMMARY DESCRIPTION OF COVERAGE

	PROGRAM ELIGIBILITY
	PERIODS OF COVERAGE AND PREMIUM RATES
	INSURANCE ENROLLMENT
	COVERAGE
	CONTINUOUS COVERAGE
	DEFINITIONS
	EXCLUSIONS
	CLAIMS PROCEDURE
	ASSISTANCE SERVICES (Available only to Participants of Health PROGRAM)
	SCHEDULE OF BENEFITS  In-Patient,  Out-Patient, and Other
	MEDICAL EVACUATION AND REPATRIATION
	Accidental Death Dismemberment
	Pre-Existing Condition Coverage Rider and Benefits
	SideTrips to Europe and Other Countries (New)
	Cancellation Policy

1)       the end of the month in which they marry; or

2)       the end of the month in which they attain the age of nineteen (19) years.

The attainment of the limiting age will not operate to terminate the coverage of such child while the child is and continues to be both:

1)       incapable of self-sustaining employment by reason of mental retardation or physical handicap; and

2)       chiefly dependent upon the Insured Person for support and maintenance.

Proof of such incapacity and dependency shall be furnished to the Company: 1) by the Named Insured; and 2) within 31 days of the child’s attainment of the limiting age.  Subsequently, such proof must be given to the Company upon request following the child’s attainment of the limiting age.

If a claim is denied under the policy because the child has attained the limiting age for dependent children, the burden is on the Insured Person to establish that the child is and continues to be handicapped as defined by subsection (1) and (2).

EXCESS PROVISION means the plan benefits are payable for covered expenses not covered and payable by any other plan providing medical expense benefits. If there is no other valid and collectible benefits available from any other source, this plan will pay the covered expenses up to the limits of the policy.

HOSPITAL means a licensed or properly accredited general hospital which; 1) is open at all times; 2) is operated primarily and continuously for the treatment of and surgery for sick and injured person as inpatients; 3) is under the supervision of a staff of one or more legally qualified Physicians available at all times; 4) continuously provides on the premises 24 hour nursing service by Registered Nurses; 5) provides organized facilities for diagnosis and major surgery on the premises; and 6) is not primarily a clinic, nursing, rest or convalescent home, or an institution specializing in or primarily treating Mental and Nervous Disorders.

HOSPITAL CONFINED/HOSPITAL CONFINEMENT: means confined in a hospital for at least 18 hours by reason of an Injury or Sickness for which benefits are payable.

INJURY means bodily injury: 1) directly and independently caused by specific accident which is unrelated to any pathological, functional, or structural disorder or injury; 2) treated by a Physician within 30 days after the date of accident; and 3) which causes loss during the term of the policy.

INSURED PERSON means: 1) the Named Insured; and 2) Dependents of the Named Insured, if: 1) the Dependent is properly enrolled in the program; and 2) the appropriate dependent premium has been paid.  The term “insured” also means Insured Person.

INTENSIVE CARE means:

1)       a specifically designated facility of the Hospital that provides the highest level of medical care; and

2)       which is restricted to those patients who are critically ill or injured.

Such facility must be separate and a part from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement.

MEDICAL EMERGENCY means the occurrence of a sudden, serious and unexpected sickness or injury.  In the absence of immediate medical attention, a reasonable person could believe this condition would result in:

1)       Death;

2)       Permanent placement of the Insured’s health in jeopardy;

3)       Serious impairment of bodily functions; or

4)       Serious and permanent dysfunction of any body organ or part.

Expenses incurred for “Medical Emergency” will be paid only for sickness or injury which fulfills the above conditions.  These expenses will not be paid for minor injuries or minor sicknesses.

MEDICAL NECESSITY means those services or supplies provided or prescribed by a hospital or physician which are:

1)       Essential for the symptoms and diagnosis or treatment of the Sickness or Injury;

2)       Provided for the diagnosis, or the direct care and treatment of the sickness or injury;

3)       In accordance with the standards of good medical practice;

4)       Not primarily for the convenience of the Insured, or the  Insured’s Physician; and

5)       The most appropriate supply or level of service which can safely be provided to the Insured.

The Medical Necessity of being hospital confined means that: 1) the Insured requires acute care as a bed patient; and 2) the Insured cannot receive safe and adequate care as an outpatient.  This policy only provides payment for services, procedures and supplies which in the judgment of the Company are a Medical Necessity.  No benefits will be paid for expenses which are determined not to be a Medical necessity, including any or all days of Hospital Confinement.

MENTAL AND NERVOUS DISORDER means a Sickness that is a mental, emotional or behavioral disorder.

NAMED INSURED means an eligible, registered or non-registered, student of the Policyholder if : 1) the student is properly enrolled in the program; an d2) the appropriate premium for coverage has been paid.

NEWBORN INFANT means any child born of an Insured while that person is insured under this policy.  Newborn infants will be covered under the policy for the first 31 days after birth.  Coverage for such child will be for Injury or Sickness, including medically diagnosed congenital defects, birth abnormalities, prematurity and nursery care; benefit swill be the same as for the Insured Person who is the child’s parent.

The Insured will have the right to continue such coverage for the child beyond the first 31 days.  To continue coverage the insured must, within the 31 days after the child’s birth: 1) apply to us; and 2) pay the required additional premium for the continued coverage.  If the Insured does not use this right as stated here, all coverage as to that child will terminate at the end of the first 31 days after the child’s birth.

PHYSICIAN means a person, other than the Insured or a member of the Insured’s family, who holds a medical license or medical certificate.

PHYSIOTHERAPY means any form of the following: physical or mechanical therapy; diathermy; ultra-sonic therapy; heat treatment in any form; manipulation or massage administered by a physician.

PRE-EXISTING CONDITION means any Injury or  Sickness that manifested itself, or for which a Physician was consulted, or for which treatment or dedication was prescribed within 6 months (12 months for insureds age 70 and older) prior to the effective date of an Insured  Person's coverage

PRE-EXISTING CONDITION WAIVER - Coverage for  pre-existing conditions will be provided for medical treatment of an  accidental bodily injury or sickness for an Insured who has maintained 6  months of continuous and uninterrupted coverage under this insurance  program. (12 months of continuous and uninterrupted coverage under this insurance program for Insureds age 70 and older)

PRESCRIPTION DRUGS means: 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a prescription legend drug; 3) any other drugs which under the applicable state or federal law may be dispensed only upon written prescription of a physician; and 4) injectable insulin.

SICKNESS means sickness or disease of the Insured Person which causes loss, and originates while the Insured Person is covered under this policy.  All related conditions and recurrent symptoms of the same or similar condition will be considered one sickness.

SOUND, NATURAL TEETH  means natural teeth, the major portion of the individual tooth is present, regardless of fillings or caps; and is not carious, abscessed or defective.

USUAL AND CUSTOMARY CHARGES means a reasonable charge which is : 1) usual and customary when compared with the charges made for similar services and supplies; and 2) made to persons having similar medical conditions in the locality of the Provider.  No payment will be made under this policy for any expenses incurred which in the judgment of the Company are in excess of Usual and Customary Charges.

EXCLUSIONS

No benefits will be paid for loss or expense caused by contributed to, or resulting from:

• Pre-existing Conditions; except for: a) for individuals who have been continuously insured for 6 months (12 months for persons 70 and older) under the policy issued to the Policyholder and b) as specifically provided for new born infants. (see Rider Override if you have chosen Rider Option)
• Any loss that occurs while traveling solely for the purpose of obtaining medical treatment while on a waiting list for a specific treatment, or while traveling against the advice of a physician;
• Expense incurred within the Insured Person’s Home Country or country of regular domicile;
• Routine physical or other examinations where there are no objective indications of impairment of normal health, or well baby care;
• Eye examinations; prescriptions or fitting of eyeglasses and contact lenses; or other treatment for visual defects and problems. "Visual defects: means any physical defect of the eye which does or can impair normal vision;
• Hearing examinations or hearing aids; or other treatment for hearing defects and problems. "Hearing defects: means any physical defect of the ear which does or can impair normal hearing;
• Dental treatment, except as the result of injury to sound, natural teeth as stated in the Schedule of Benefits:
• Professional services rendered by a Member of the Insured Person’s immediate family, or anyone who lives with the Insured Person;
• Services or supplies not necessary for the medical care of the patient’s injury or sickness;
• Weak, strained or flat feet, corns, calluses, or toenails;
• Cosmetic surgery, or treatment for congenital anomalies, except reconstructive surgery as the result of a covered Injury or Sickness. Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or covered Sickness;
• Elective Surgery and Elective Treatment;
• Diagnostic or surgical procedures in connection with infertility unless infertility is a result of a covered Injury or covered Sickness;
• Birth control, including surgical procedures and devices;
• Routine new-born baby care, well-baby nursery and related Physician charges;
• Injury or Sickness for which benefits are paid or payable under any Worker’s Compensation or Occupational Disease Law or Act, or similar legislation;
• Organ transplants;
• War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered);
• Participation in a riot or civil disorder, commission of or attempt to commit a felony in the country in which it was attempted or committed;
• Suicide or attempted suicide (including drug overdose), while sane or insane (while sane in Missouri), or intentionally self-inflected Injury;
• Charges of an institution, health service, or infirmary for whose service payment is not required in the absence of insurance;
• Loss incurred from riding in any aircraft, other than as a passenger in an aircraft licensed for the transportation of passengers;
• Treatment services, supplies or facilities in a hospital owned or operated by: a) The Veteran’s Administration; or b) A national government or any of its agencies. (This exclusion does not apply to treatment when a charge is made which the Insured is required by law to pay);
• Duplicate services actually provided by both a certified nurse-midwife and Physician;
• Expenses payable under any prior policy which was in force for the person making the claim;
• Expenses incurred during a hospital emergency room visit which is not of an emergency nature;
• Expenses incurred for outpatient treatment in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or sublimation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;
• Injury sustained as the result of the Insured operating a motor vehicle while not properly licensed to do so in the jurisdiction the motor vehicle accident occurs;
• Voluntary or elective abortion except as specifically provided;
• Expense covered by any other valid and collectible medical, health or accident insurance;
• Expense incurred after the date insurance terminates for an Insured Person except as may be specifically provided in the Extension of Benefits Provision;
• Expenses incurred for injuries resulting from the use of alcohol or intoxicants, or any drugs unless prescribed by a Physician;
• Sexually transmitted diseases, including AIDS.

(800) 551-0824  or  (302) 661-4176

• Helping to obtain local medical care.
• Monitoring hospitalizations and maintaining contact between attending physicians and family physicians.
• Arranging medical evacuations and treatment en-route if necessary.
• Arranging family, business associates, or friends to join the ill traveler.
• Arranging repatriation of remains in the event of the insured's death.

Up-to-the-minute information available on:

• U.S. State Department and private service warnings about travel to certain locations.
• Immunizations requirements.
• Passport and Visa requirements.
• Emergency transfer of funds;
• Weather conditions and hazards particular to certain locations.

Chartis Assist provides:

• Emergency registry services for vital, confidential, personal, and medical information.
• 24-hours emergency travel service for airline and hotel reservations.
• Help in replacing lost baggage and lost passports.

Chartis Assist can also:

• Arrange for local legal assistance.
• Act as a 24-hour toll free/collect emergency message center.
• Assist with emergency cash transfers and credit card advances based on the insured's resources.
• Co-ordinate insurance documents and claims submissions.

The Chartis Assist communications network is available 24 hours a day, seven days a week to provide assistance to the traveler. In the United States and Canada call 1-800-626-2427. Outside of the United States call 0-713-267-2525 (collect call only).

SCHEDULE OF BENEFITS

PART A

When your covered Injury or Sickness requires treatment by a Physician, the Policy will provide benefits while your coverage is in force for the Usual and Customary (U&C) charges subject to the maximums shown below which exceed a $75 deductible Per Person for each Injury and each Sickness. Payment for any Covered Service will be no more than the Benefit Limit shown for it. The total payable by all Benefits will be no more than the stated policy maximum for each Injury and each Sickness. The $250 deductible and $500 deductible options include the same Covered Services and Benefit Limits as described below for 70 plus visitors.

COVERED SERVICES INJURY AND SICKNESS BENEFIT LIMITS (U&C Below means Usual and Customary Charges)

INCIDENTAL SIDE TRIPS