STUDENT ACCIDENT POLICY

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1 STUDENT ACCIDENT POLICY Underwritten by United State Fire Insurance Company Policy Number: US RMC 17/18

2 TABLE OF CONTENTS INTRODUCTION...3 ELIGIBILITY...3 POLICY TERM...4 ACCIDENT BENEFITS DEFINITIONS...6 FIRST HEALTH NETWORK...7 CLAIM PROCEDURE...8 SUBROGATION...9 ACCIDENTAL DEATH AND DISMEMBERMENT...9 EXCLUSIONS IMPORTANT INFORMATION...13

3 INTRODUCTION This brochure is a brief summary of the School- Sponsored Student Accident Insurance Plan for students at Randolph- Macon College. The exact benefits, limitations and exclusions governing this plan are contained in the Master Certificate (GAC26932) issued to Randolph-Macon College on site at the school. The Master Certificate shall control in the event of any discrepancy between the Master Certificate and this brochure. We suggest that you retain this brochure so you will have a ready reference to the benefits of the Plan. Any provision of the Master Certificate or the brochure, which is in conflict with the statutes of the state in which the Master Certificate is issued, will be administered to conform with the requirements of such state statutes. We know that your privacy is important to you and we strive to protect the confidentiality of your non-public personal information. We do not disclose any non-public personal information about our insureds or former insureds to anyone, except as permitted or required by law. We maintain appropriate physical, electronic and procedural safeguards to ensure the security of your non-public personal information. You may obtain a detailed copy of our privacy policy through your school, or by calling A-G Administrators at or by visiting: www. agadministrators.com. ELIGIBILITY Randolph-Macon College students taking 12 or more credits or taking 3 or more classes in one semester are automatically provided by the College with the Basic Student Accident Coverage. If an eligible student is required to be on campus to participate in a school sponsored activity prior to the effective date, coverage for that student begins on the day they are required to be on campus for that activity. If such a covered student is injured and unable to attend classes, that student will be insured to the end of the policy term for which payment has been made

4 POLICY TERM Coverage begins at 12:01 AM July 1, 2017 and continues until 12:01 AM on July 1, Students who enroll for the fall semester, will be covered until 12:01 AM on July 1, New incoming spring students, coverage begins at 12:01 AM January 1, 2018 and continues until 12:01 AM on July 1, ACCIDENT BENEFITS The maximum benefit is $5,000 for each accident. This policy pays on an excess basis, or after all other plans which the insured is covered under, have paid first. There is no deductible. There is $5,000 of intercollegiate sports injuries covered under this plan. When hospital or medical care is required for a covered injury, the plan will pay covered medical expenses incurred (up to the Reasonable and Customary charges). The plan pays for the following eligible expenses: (a) treatment by a physician or surgeon; (b) services of an anesthetist or anesthesiologists; (c) hospital confinement; (d) services of a licensed practical nurse or RN; (e) x-ray service; (f) use of an operating room, anesthesia, laboratory service; (g) surgical dressings, medicines, plaster casts, splints, use of a wheelchair or crutches; (durable medical equipment) or other braces and appliances; (h) use of an ambulance; (i) use of an ambulatory surgical center of ambulatory medical center; (j) if ordered by a physician, prescription medicines, drugs or any other therapeutic services or supplies and physical/occupational therapy as related to an injury. NOTE: Treatment must begin within 180 days of the accident. The benefit period is 104 weeks from the date of the injury. For questions regarding this plan, please contact A-G Administrators at Plan Maximum $5,000 Intercollegiate Sports $5,000 Accidental Death and Dismemberment $5,

5 HEART AND CIRCULATORY BENEFIT Benefits will be payable on the same basis as any other injury for treatment of an acute onset of conditions relating to the heart and/or circulatory system that result from injury during play, practice or conditioning of Intercollegiate Sports. These conditions are heart attack, stroke, brain circulatory malfunctions and heat exhaustion. Benefits are subject to the same limitations. Deductible, coinsurance, and copay as any other injury. EXPANDED MEDICAL TREATMENT BENEFIT Benefits will be payable on the same basis as any other injury for treatment of the following conditions resulting from the play or practice of Intercollegiate Sports: Repetitive Motion Injuries; Strains; Sprains; Hernia; Tennis Elbow; Tendonitis; Bursitis; and Muscle tears. Benefits are subject to the same limitations, Deductible, coinsurance and copay as any other injury. RE-AGGRAVATION OF PRIOR SPORTS INJURY During play or practice of intercollegiate sports, benefits are payable for re-aggravation of a sports injury suffered prior to the Effective Date of a covered person s coverage under the Policy. For the purposes of this Re-aggravation of Prior Sports Injury benefit only, such re-aggravation will be considered an Injury if the re-injury occurs under circumstances which would have otherwise been covered under the Policy. Any exclusion for congenital conditions, sickness, or disease remains in force. The maximum amount payable under this Re-aggravation of Prior Sports Injury benefit is limited to the amount shown on the Schedule of Benefits. This amount is included in the Aggregate Maximum Benefit Amount, per covered person, per accidental injury, as shown on the Schedule of Benefits, and is not in addition to that amount. HMO/PPO PROVISION In the event that Covered Expenses are denied under a Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), or other group medical plan you have in force, and such denial is because care or treatment was received outside of the network s geographic area, benefits will be payable under this coverage, provided the expense is a Covered Expense

6 DEFINITIONS Accident means a sudden, unforeseeable external event which: (1) Causes Injury to one or more Covered Persons; and (2) Occurs while coverage is in effect for the Covered Person. Covered Person means a person eligible for coverage as identified in the Application for whom proper premium payment has been made, and who is therefore insured under the Master Certificate. Doctor means a licensed practitioner of the healing arts acting within the scope of his license. Doctor does not include: (1) The Covered Person; (2) The Covered Person s spouse, child, parent, brother, or sister; or (3) A person living with a Covered Person. Eligible Expenses means the Usual, Reasonable and Customary charges for services or supplies which are incurred by the Covered Person for the Medically Necessary treatment of an Injury. Eligible Expenses must be incurred while the Master Certificate is in force. Injury means bodily harm which results, directly and independently of disease or bodily infirmity, from an Accident. All injuries to the same Covered Person sustained in one accident, including all related conditions and recurring symptoms of the Injuries will be considered one Injury. Medically Necessary or Medical Necessity means the service or supply is: (1) Prescribed by a Doctor for the treatment of the Injury; and (2) Appropriate, according to conventional medical practice for the Injury in the locality in which the service or supply is given. Usual, Reasonable and Customary means: (1) With respect to fees or charges, fees for medical services or supplies which are; (a) Usually charged by the provider for the service or supply given; and (b) The average charged for the service or supply in the locality in which the service or supply is received; or (2) With respect to treatment or medical services, treatment which is reasonable in relationship to the service or supply given and the severity of the condition

FIRST HEALTH NETWORK Persons insured under this Plan may choose to be treated within or outside of the My First Health Preferred Provider Network.

7 FIRST HEALTH NETWORK Persons insured under this Plan may choose to be treated within or outside of the My First Health Preferred Provider Network. The My First Health Preferred Provider Network consists of hospitals, physicians, and other health care providers organized into a network for the purpose of delivering quality health care at affordable rates. In order to use the services of a participating provider, you must present an identification card which is issued to all students insured under the Randolph-Macon Student Accident Insurance Plan. The availability of specific providers is subject to change without notice. You should always confirm that a Preferred Provider is participating at the time services are required by checking the Preferred Provider Network website or by calling the Preferred Provider Network and by asking the provider when you make an appointment for services. You may check for My First Health Preferred Providers by calling or visiting: com. Preferred Providers are the Doctors, hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices

8 CLAIM PROCEDURE In the event of an Injury, the Covered person should: 1. Complete a claim form and mail it to A-G Administrators within 30 days of the date of the Injury or as soon thereafter as possible. Mail the claim form to: A-G Administrators, Inc. P.O. Box 979, Valley Forge, PA or fax to Claim forms are available online at www. cirstudenthealth.com/rmc or by calling A-G Administrators at If the providers have given you bills, attach them to the claim form. 3. Direct all questions regarding benefits available under this Plan, claim procedures, status of a submitted claim or payment of a claim to by calling A-G Administrators at Itemized medical bills must be attached to the claim form at the time of submission. Subsequent medical bills received after the initial claim form has been submitted should be mailed promptly to A-G Administrators. No additional claim forms are needed as long as the Covered person s name and identification number are included on the bill

9 SUBROGATION When benefits are paid to or for a person under the terms of the policy, we shall be subrogated, unless otherwise prohibited by law, to the rights of recovery of such person against any person who might acknowledge liability or found legally liable by a Court of competent jurisdiction for the sickness or injury that necessitated the hospitalization or the medical or the surgical treatment for which the benefits were paid. Such subrogation rights shall extend only to the recovery by us of the benefits we have paid for such hospitalization and treatment and we shall pay fees and costs associated with such recovery. The person agrees to sign papers and do whatever else is necessary to transfer his rights to us. We will exercise such rights on his behalf. He further agrees to furnish us with all relevant information and documents. ACCIDENTAL DEATH AND DISMEMBERMENT If the Covered Person sustains any of the following losses as the result of a covered Accident, within 365 days after the date of Accident, the Company will pay the amount shown: For Loss of Amount Life...$5,000 Both hands or both feet or sight of both eyes...$5,000 One hand and one foot...$5,000 One hand and sight of one eye...$5,000 One foot and sight of one eye...$5,000 One hand or one foot or sight of one eye...$2,500 Loss of a hand or foot means complete severance through or above the wrist or ankle joint. Loss of sight of an eye means the total, irrevocable loss of the entire sight in that eye. Severance means the complete separation and dismemberment of the part from the body. If a Covered Person suffers more than one loss as a result of the same Accident, the Company will pay only for the loss with the largest benefit

10 EXCLUSIONS Benefits will not be paid for a Covered Person s loss which: 1. Is caused by or results from the Covered Person s own: (a) Intentionally self inflicted Injury, suicide or any attempt thereat; (b) Voluntary self administration of any drug or chemical substance not prescribed by, and taken according to the directions of, a doctor (Accidental ingestion of a poisonous substance is not excluded.); (c) Commission or attempt to commit a felony; (d) Participation in a riot or insurrection; (e) Under the influence of a controlled substance unless administered on the advice of a doctor; or 2. Is caused by or results from: (a) Declared or undeclared war or act of war; (b) An Accident which occurs while the Covered Person is on active duty service in any Armed Forces. (Reserve or National Guard active duty for training is not excluded unless it extends beyond 31 days.); (c) Aviation, except as specifically provided in this Certificate; (d) Sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, bacterial or viral infection, regardless of how contracted, [unless a Sickness Expense Rider is in force under this Certificate]. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning. ADDITIONAL EXCLUSIONS Benefits will not be paid for: 1. Normal health checkups; 2. Dental care or treatment other than care of sound, natural teeth and gums required on account of Injury resulting from an Accident while the Covered Person is covered under this Certificate, and rendered within 6 months of the Accident; 3. Services or treatment rendered by a doctor, nurse or any other person who is: (a) Employed or retained by the Certificate holder; or (b) Who is the Covered Person or a member of his immediate family; 4. Charges which: (a) The Covered Person would not have to pay if he did not have insurance; or (b) Are in excess of Usual, Reasonable and Customary charges; 5. An Injury that is caused by flight in: (a) An aircraft, except as a fare paying passenger; (b) A space craft or

11 any craft designed for navigation above or beyond the earth s atmosphere; or (c) An ultra light, hang gliding, parachuting or bungee cord jumping; 6. Injury that is: (a) The result of the Covered Person being Intoxicated. ( Intoxicated will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs); or (b) Caused by any narcotic, drug, poison, gas or fumes voluntarily taken, administered, absorbed or inhaled, unless prescribed by a doctor; 7. Practice or play in any sports activity, including travel to and from the activity and practice, unless specifically provided for in this Certificate, in excess of $2,000; 8. Elective treatment or surgery, health treatment, or examination where no Injury is involved; 9. Injury sustained while in the service of the armed forces of any country. When the Covered Person enters the armed forces of any country, we will refund the unearned pro rata premium upon request; 10. Eyeglasses, contact lenses, hearing aids, braces, appliances, or examinations or prescriptions therefore; 11. Treatment in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay; 12. Cosmetic surgery, except for reconstructive surgery on a diseased or injured part of the body; 13. Any loss which is covered by state or federal worker s compensation, employers liability, occupational disease law, or similar laws

13 IMPORTANT INFORMATION STUDENT HEALTH CENTER Phone CLAIM ADMINISTRATOR Claim, benefit questions and online claim status: A-G Administrators P.O Box 979 Valley Forge, PA Phone Fax Website... PARTICIPATING PROVIDERS For a list of participants: Phone Website... BROKERED BY USI Student Insurance Division Phone Please cut out the Accident ID Card below and keep it with you, in case you have an injury. RANDOLPH-MACON COLLEGE STUDENT ACCIDENT ID CARD Name Policy #: US Effective Dates of Coverage: 7/1/17-7/1/18 Underwritten by United States Fire Insurance Company

14 CLAIMS AND BENEFITS: A-G Administrators P.O. Box 979, Valley Forge, PA Phone: Fax: NOTE: This plan only applies to students taking 12 or more credits or taking 3 or more classes in one semester

STUDENT ACCIDENT INSURANCE PLAN

STUDENT ACCIDENT INSURANCE PLAN Designed for Undergraduate Students of: (the Policyholder ) Rockland Campus 1 South Boulevard Nyack, NY 10960 2016-2017 Policy Number US 562773 Underwritten by: United States