Kennebec Valley Community College

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2018 2019 STUDENT INSURANCE PLAN Plan 1 Accident-Only Insurance Policy No. 2018J3A68 Plan 2 Student Accident & Sickness Indemnity Insurance Plan Policy No.

1 STUDENT INSURANCE PLAN Plan 1 Accident-Only Insurance Policy No. 2018J3A68 Plan 2 Student Accident & Sickness Indemnity Insurance Plan Policy No. 2018J3A69 Effective 8/15/18 8/15/19 Kennebec Valley Community College Fairfield, Maine Underwritten by: Claims Administered by: Serviced by: 70 Genesee Street Utica, NY Mill Street, 4th Floor, Suite 4 Lewiston, ME Product underwritten by National Guardian Life Insurance Company (NGL), Madison, WI. National Guardian Life Insurance Company is not affi liated with The Guardian Life Insurance Company of America a.k.a. The Guardian or Guardian Life. as policy form # Accident-Only: NSP-2013ME / Indemnity: NGRPHIP(S)-ME 6/12 18-J3A68/69 (Bro.)

2 Kennebec Valley Community College Student Insurance This informational pamphlet outlines the Plan 1: Student Accident Only and Plan 2: Accident and Sickness Indemnity Insurance Plan. The need for protection against unexpected medical expenses that may be incurred as a result of an accident or sickness, is obvious. These expenses can seriously deplete the finance resources earmarked for educational purposes. Eligibility: All matriculated students (students in a program) are eligible for coverage under Plan 1 and Plan 2. Plan 1: In the fall, all eligible students are automatically enrolled in the Accident-Only Insurance Plan 1 and billed an annual premium of $30. Plan 1 coverage is effective on August 15, 2018 and expires on August 15, New students in the spring would have coverage effective January 1, 2019 to August 15, 2019, and the premium amount is $15. Accident benefits are provided for incurred eligible Medical Expenses up to $2,000, payable at 100% of Usual and Customary for Covered Medical Expenses incurred as inpatient or outpatient, as a result of a Covered Accident until the termination date or any extension of benefits of the policy, subject to all policy provisions. Plan 2: All eligible students can choose to purchase the optional Plan 2, Accident and Sickness Indemnity Insurance Plan on a voluntary basis. Plan 2 coverage is effective August 15, 2018 and terminates on August 15, The premium amount is $450. For new students in the spring, coverage would be effective January 1, 2019 to August 15, 2019, and the premium would be $302. To enroll in this optional Plan 2, complete the enclosed enrollment form and return it to the business office by August 15, 2018 or for spring by January 1,

3 PLAN 1 ACCIDENT-ONLY BENEFITS Benefit Period: Policy Term Provided under Policy No. 2018J3A68 Maximum Medical Benefit: $2,000 Coverage: If the Insured Person incurs eligible expense as the result of a covered Injury, we will pay the charges incurred for such expense within the Benefit Period, beginning on the date of accident. Payment will be made for eligible expenses in excess of the applicable Deductible Amount, not to exceed the Maximum Medical Benefit. The first such expense must be incurred within 60 days after the date of Accident. Eligible Expense means the Usual and Customary charges incurred for the following treatments and services as the result of a covered Injury: 1) Medical and surgical care by a physician; 2) Hospital care and service in semi-private room, or as an outpatient; 3) Radiology (X-rays); 4) Orthopedic appliances necessary to promote healing; 5) Ambulance service from the scene of the Accident to the nearest Hospital; 6) Dental treatment of sound natural teeth, not to exceed the Maximum Dental Benefit stated in the Policy Schedule as the result of one Accident. Coverage is provided for activities within a school building or on the school grounds during regular school hours on a regular school day; away from school premises while participating in an activity solely sponsored and supervised by the school authorities, during the regular school term; or away from school premises while coverage is in force. Extension of Benefits: Coverage under the Policy ceases on the Termination Date shown in the Policy Schedule. However, coverage for the Insured will be extended if an Insured is Hospital confined for Covered Injury on the date of his or her insurance terminates, we will continue to pay benefits for up to a minimum of 31 days from the Termination Date while such confinement continues. PLAN 1 EXCLUSIONS AND LIMITATIONS The Policy does not cover any loss contributed to or resulting from: 1. Sickness or disease in any form (except pyogenic infections due to an accidental cut or wound). 2. The use of drugs or narcotics; unless administered on the advice of a physician. 3. War or any act of war, whether or not declared 4. Participation in any riot or civil commotion. 5. Air travel; or the use of any device or equipment for aerial navigation; except as a fare-paying passenger on a regularly scheduled commercial airline; or as a passenger on a flight chartered by the School. 6. Suicide, attempted suicide, or intentionally self-inflicted injury. 7. Hernia, in any form. 8. Fighting or brawling. 9. Use of electric, bio-mechanical devices. 10. Expenses incurred for the use of Orthotics unless solely to promote healing. 11. Off season physical conditioning for interscholastic, intercollegiate, intramural, or club sports; unless noted on the Policy Schedule. The Policy does not cover treatment administered by any person or facility employed or retained by the Policyholder; or by any member of the Insured s family or household. This includes a team Physician, team trainer or nurse. PLAN 1 NON-DUPLICATION OF INSURANCE PROVISION The Policy does not cover treatment or service for which benefits are payable or service is available under any Other Valid and Collectible Insurance. This includes Worker s Compen sa tion and automobile no-fault insurance. Benefits under the Policy are limited to expenses that are in excess of benefits payable under other valid and collectible insurance. 3

4 PLAN 2 SCHEDULE OF BENEFITS 1. ELIGIBILITY ELIGIBLE PERSONS ARE: Eligible Class(es) Description 1 All matriculated Students THE ELIGIBLE CLASS(ES) MAY BE AFFORDED THE FOLLOWING COVERAGES: Coverage Description Eligible Class(es) 24-Hour Accident & Sickness Coverage 1 (on a voluntary basis) 2. COVERAGE PERIOD: Begins on August 15th and ends on August 15th of the next year. 3. COVERED SERVICES AND BENEFIT AMOUNTS: Hospital Confinement Daily Income Benefit* Daily benefit for non-critical care unit $ Maximum benefit for non-critical care unit per Coverage Period 20 daily benefits combined Doctors Visits Benefit Daily benefit (10 daily benefits per Coverage Period) $ Diagnostic Laboratory Tests Benefit Daily benefit for all laboratory tests (3 daily benefits per Coverage Period) $ Diagnostic Radiology Tests Benefit Daily benefit for all other radiology tests (3 daily benefits per Coverage Period) $ Wellness Care Visits Benefit Daily benefit for an annual physical (1 daily benefit per Coverage Period) $ Ambulance Transportation Benefit Daily benefit for a trip in an ambulance (1 daily benefit per Coverage Period) $ Emergency Room (ER) Visits Benefit Daily benefit for an ER visit for the treatment of a Sickness (1 daily benefit per Coverage Period) $ Daily benefit for an ER visit for the treatment of an Injury (1 daily benefit per Coverage Period) $ Surgery Benefit Daily benefit per surgery performed as an Inpatient (2 daily benefits per Coverage Year) $ per day Daily benefit per surgery performed as an Outpatient (2 daily benefits per Coverage Year) $ per day Administration of Anesthesia Benefit Daily benefit per administration performed as an Inpatient (2 daily benefits per Coverage Year) $ per day Daily benefit per administration performed as an Outpatient (2 daily benefits per Coverage Year) $ per day Private-duty Nursing Care and Home Health Care Benefit Daily benefit per session/visit $ Maximum benefit for all sessions/visits per Coverage Period 4 daily benefits Generic Prescription Drug Benefit Daily benefit per generic drug prescription filled or refilled $ Generic drug maximum benefit per Coverage Period 10 daily benefits Hospital Discharge Benefit Daily benefit per day of Inpatient confinement $ Maximum benefit per Coverage Period 5 daily benefits Maximum number of Hospital discharges per Coverage Period 1 4

5 4. INDIVIDUAL EFFECTIVE DATE: The following will apply to the noted classes of Eligible Persons. All matriculated Students - The first of the month following the date such person comes within the classification of Eligible Persons. 5. PREMIUM SCHEDULE: Eligible Class(es) Initial Annual Premiums Class 1 - Covered Person Only $

6 Definitions Accident means a sudden, unforeseeable event that causes Injury to a Covered Person. Sickness means Sickness or disease of a Covered Person. Extension of Benefits If coverage under the policy ends due to policy termination and the Covered Person is confi ned to a Hospital as an Inpatient, benefi ts for that Hospital confi nement will be paid as though the policy had not terminated. If coverage under the policy ends other than due to policy termination and the Covered Person is totally disabled due to Injury or Sickness, we will pay benefi ts for covered services occurring after the date coverage under the policy ends as long as they meet the following requirements: a) the covered service must be rendered due to the same Injury or Sickness causing the Covered Person to be totally disabled on the date coverage ends; and b) the covered service must occur within 90 days after the date the Covered Person s coverage under the policy ends; and c) coverage must not have ended as a result of the Covered Person s voluntary termination of the coverage. This extension of benefi ts terminates at the end of the 90-day period specifi ed above. Exclusions Exclusion Disclaimer: Any exclusion in conflict with the Patient Protection and Affordable Care Act will be administered to comply with the requirements of the Act. No benefits will be paid for loss caused by or resulting from: 1) intentionally self-inflicted injuries, suicide or any attempt thereat while sane or insane; 2) declared or undeclared war or any act thereof; 3) the Covered Person s commission of a felony; 4) the Covered Person s participation in, practice for, or orthopedic equipment and appliances used for; Intercollegiate tackle football; Intercollegiate sports; semi-professional sports; or professional sports, (except as specified in the Coverage Descriptions); 5) the Covered Person operating any vehicle while under the influence of alcohol or without being properly licensed and insured to do so; 6) work-related Injury or Sickness; this exclusion applies even if a Covered Person is exempt from state workers compensation requirements or has filed an exemption from the Workers Compensation law 7) the Covered Person s use of drugs or alcohol, unless administered by a Doctor; In addition to the above exclusions, no benefits will be paid for: 1) eye examinations for glasses; any kind of eye glasses, or prescriptions for any eyeglasses except as required as a result of a covered Injury; 2) hearing examinations or hearing aids except as required as a result of a covered Injury; 3) dental care or treatment other than covered services rendered in connection with the care of sound, natural teeth and gums required on account of Injury to the Covered Person resulting from an Accident that happens while covered under the policy, and rendered within 12 months of the Accident; 4) care or treatment of allergies, including allergy testing; 5) diagnosis and care or treatment of acne; 6) care or treatment of Injury to the Covered Person resulting from a motor vehicle Accident; 7) care or treatment rendered in connection with cosmetic surgery, except covered services rendered in connection with cosmetic surgery the Covered Person needs for breast reconstruction following a mastectomy or as a result of an Accident that happens while covered under the policy. Cosmetic surgery for an accidental Injury must be performed within 90 days of the Accident causing the Injury and while such person s coverage is in force; 8) care or treatment rendered in connection with surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices other than as specifically provided above; 9) care or treatment rendered to a Covered Person while outside the United States of America; 10) services provided by a member of the Covered Person s immediate family; 11) services provided by the Policyholder s infirmary or its employees, or Doctors who work for the Policyholder or at any Student Health Center. This plan provides limited accident and sickness coverage. It is not a substitute for comprehensive health insurance coverage and does not qualify as minimum essential health coverage under the Affordable Care Act. Claim Procedure In the event of Accident or Sickness the student should: 1. If at school, report immediately to the Student Services Office so that proper treatment can be prescribed or approved. 2. If away from the School, consult a doctor and follow his advice. Notify the Student Health Services or the Claims Administrator within 30 days of the covered accident or commencement of covered illness, or as soon thereafter as is reasonably possible. 3. Claim forms can be obtained on-line from Cross Insurance at: 4 Submit the completed claim form, together with copies of itemized bills and your other insurance carrier s Explanation of Benefits, within 90 days after first treatment to Commercial Travelers. (The address is on the claim form.) 6

7 Claims Administered By: Commercial Travelers Life Insurance Company 70 Genesee St. Utica, NY Electronic Claim Payor ID #: Serviced By: Cross Insurance 150 Mill St., Fourth Floor, Suite 4 Lewiston, ME (207) or Website: http// Representations of this plan must be approved by the Company. This is not the Policy. Rather, it is a brief description of the benefits and other provisions of the Policy. The Policy is governed by the laws and regulations of the state in which it is issued and is subject to any necessary State approvals. Any provisions of the Policy, as described in this brochure, that may be in conflict with the laws of the state where the school is located will be administered to conform with the requirements of that state s laws, including those relating to mandated benefits. ID CARD Name of Insured KENNEBEC VALLEY COMMUNITY COLLEGE PLAN 1 Plan 1 Policy No. 2018J3A68 Plan 2 Policy No. 2018J3A69 Claims to: Commercial Travelers 70 Genesee St. Utica, NY Electronic Claim Payor ID #: Possession of this card does not guarantee eligibility. The student must be enrolled in the plan. Eligibility is subject to Verification by Plan Administrator. FOLD Claims Paid and Plan Adminstered by: Commercial Travelers 70 Genesee Street Utica, NY (800) Fully Insured and Underwritten by: National Guardian Life Insurance Company Madison, WI 7

Student Fixed Indemnity Accident and Sickness Plan. Alabama Agricultural and Mechanical University Normal, Alabama

Student Fixed Indemnity Accident and Sickness Plan Alabama Agricultural and Mechanical University Normal, Alabama 2015-2016 Policy Number: 2015I5A54 Group Number: S211109 Underwritten by NATIONAL GUARDIAN