When They re Protected, You re Protected.

Size: px

Start display at page:

Download "When They re Protected, You re Protected."

Julius Griffin
6 years ago
Views:

1 When They re Protected, You re Protected. Student/Athletic/Activities Zero Deductible Gap Accident Medical Program Plan Summary of Coverages for Association/School Sponsored and Supervised Sports and Activities A Division of Planned Benefit Services

2 Today, educational institutions offer a wide range of opportunities to enrich the lives of our children. Sponsored and supervised activities provide students with dynamic, new ways to understand the world beyond the classroom setting. When accidents occur during sponsored and supervised school activities, it can present potential liability to schools as well as financial and emotional hardship to affected families. At Team Assure, our knowledgeable and experienced staff understands the specific risks involved in student participation in teams, squads, clubs or associations. We provide comprehensive programs through our top rated insurance carriers designed to give your group the coverage it needs and the peace of mind you want. Supplemental Excess & Secondary Accident Only Student/Athletic Zero Deductible Medical Program Medical Expenses will be reimbursed to cover Usual and Reasonable charges for expenses incurred for Medical and Dental Services. Eligibility More than 3.5 million children ages 14 and under get hurt annually playing sports or participating in recreational activities.* All enrolled students of the State High School Athletic/ Activities Association Member Schools or other Associations or Individual Entities who *Statistics from the National SAFE KIDS Campaign and the American Academy of Pediatrics (AAP). participate in sponsored and supervised sports, including student players, coaches, managers, and volunteers of the team(s), band, cheerleaders, majorettes, student coaches, student trainers, and student-managers and employees that are named and specified in the application and paid for. Covered Activity Interscholastic Sports, We measure our performance according Extracurricular and Curricular Activities to the impact that we have helping our Interscholastic competitions and activities that are member schools parents & students authorized, sanctioned or scheduled by the participant receive the best in medical care. and related Covered Travel as defined in the Benefits Plan as well as other activities of the association and/or school.

The Basis of Benefits See the Plan Summary for Details Accidental Injury Means an unexpected or unforeseen event occurring suddenly and violently, with or without human fault, and causing at the time

3 The Basis of Benefits See the Plan Summary for Details Accidental Injury Means an unexpected or unforeseen event occurring suddenly and violently, with or without human fault, and causing at the time physical injury to the body or damage to an artificial member of the body, and taking place not according to the usual course of events (for example a motor vehicle accident). Accidental injury does not include any damage caused by chewing or biting on any object. Medically Necessary Means that a Covered Accident Medical Service or Dental Service: (1) is essential for diagnosis, treatment or care of the injury for which it is prescribed or performed; (2) meets generally accepted standards of medical practice; (3) is ordered by a Physician and performed under his or her care, supervision or order. Usual & Reasonable Reimbursement Means the benefit plan described is an Association Plan Sponsored and Supervised by the participants on behalf of its participating members. The plan will reimburse the plan member for expenses that are considered patient responsibility under federal tax code medical reimbursement guidelines. The reimbursement amount is limited to the amount that is normally paid by the most common payer or an average of the amount normally paid by Medicare, Medicaid and Blue Cross and Blue Shield group and individual plans. Maximum Allowable Reimbursement Expense Means the benefit plan has overall scheduled maximum benefits, based on the actual plan selected by each school/association. Accident Medical Maximum Medical Expenses will be reimbursed to cover Usual and Reasonable charges for expenses incurred for Medical and Dental Services up to plan limits. Plan is NOT a Major Medical Plan The Plan is a supplemental excess and secondary Accident Only plan and is considered an Excepted Benefit Plan as defined at ERISA section 733(c) under the Affordable Care Act. This plan is designed to pay for certain deductibles, co-payments and other limited expenses that may not be covered by a parent s major medical plan. The State High School Athletic/Activities Association or other Associations or Individual Entities and the participating schools assume that parents have a Major Medical Health Plan in place. If you do not have a major medical plan in place on your child, please contact your school or our office and we will assist you in applying for such coverage from Medicare, Medicaid, All Kids, Chips and Blue Cross and Blue Shield group and individual plans. Accident Medical Expense When a covered injury to a Plan Participant results in the treatment by a legally qualified physician beginning within 30 days after the date of accident, and a notification of injury form is filed within 90 days of injury, the Plan will pay medically necessary benefits as shown in the Schedule of Benefits. Covered eligible medical expenses are those incurred by the plan participant during a 52 week period following the date of injury. Benefits for any one accident shall not exceed, in the aggregate, the maximum allowable reimbursements expense established for each school.

4 This is a Supplemental Excess & Secondary Accident Only Student/Athletic Medical Program* Plan Benefit Highlights Treatment must be prescribed by a Legally Qualified Physician Treatment must commence within 30 days of injury No Deductible to Satisfy Accident Medical Plan Maximum Benefits Provided on an Excess and Secondary Medical Reimbursement Basis Notification of Injury Form must be filed within 90 days of injury Plan Benefit Period up to 52 weeks from the date of injury Travel directly to and from covered events or activities which is approved, sponsored and supervised by a school official in a vehicle which is approved, sponsored and supervised and driven by an approved and properly licensed driver over 22 years of age. Plan is NOT a Major Medical Plan The Plan is a supplemental excess and secondary Accident Only plan. This plan is designed to pay for certain deductibles, co-payments and other limited expenses that may not be covered by a parent s major medical plan. The State High School Athletic/Activities Association or other Associations or Individual Entities and the participating schools assume that parents have a Major Medical Health Plan in place. If you do not have a major medical plan in place on your child, please contact your school or our office and we will assist you in applying for such coverage from Medicare, Medicaid, All Kids, Chips and Blue Cross and Blue Shield group and individual plans. However, if a child has no other insurance at the time of injury this plan will pay the benefits outlined below. *Plan selected varies by state/school Plan Summary 5 STAR PLAN 4 STAR PLAN 3 STAR PLAN INDIVIDUAL INPATIENT HOSPITAL SERVICES 1. Room & Board U&R 80% of U&R 60% of U&R U&R 2. Hospital Miscellaneous U&R 80% of U&R 60% of U&R U&R 3. Intensive Care U&R 80% of U&R 60% of U&R U&R 4. Registered Nurse U&R 80% of U&R 60% of U&R U&R 5. Physician s Visits U&R 80% of U&R 60% of U&R U&R OUTPATIENT HOSPITAL SERVICES 1. Emergency Room Services U&R 80% of U&R 60% of U&R U&R 2. Outpatient Surgery Services U&R 80% of U&R 60% of U&R U&R PHYSICIANS SERVICE 1. Surgery, including pre- and post-operative care U&R 80% of U&R 60% of U&R U&R 2. Anesthetic (including administration) U&R 80% of U&R 60% of U&R U&R 3. Assistant Surgeon U&R 80% of U&R 60% of U&R U&R 4. Physician s visits (other than for Physiotherapy or similar treatment when no surgery is performed) U&R 80% of U&R 60% of U&R U&R X-RAY, DIAGNOSTIC AND LABORATORY SERVICES 1. X-Rays, CAT Scans and MRI s including fees for reading and interpretation U&R 80% of U&R 60% of U&R U&R 2. Laboratory and Diagnostic service U&R 80% of U&R 60% of U&R U&R ADDITIONAL SERVICES 1. Ambulance to or from hospital (ground transport only) U&R 80% of U&R 60% of U&R U&R 2. Prescribed Drugs and Medicines U&R 80% of U&R 60% of U&R U&R 3. Artificial limbs, artificial eyes or other prosthetic appliances, when prescribed by a Doctor U&R 80% of U&R 60% of U&R U&R 4. Registered or licensed Nurse U&R 80% of U&R 60% of U&R U&R 5. Blood, blood products and artificial blood products, and the transfusion there of U&R 80% of U&R 60% of U&R U&R 6. Rental of durable medical equipment U&R 80% of U&R 60% of U&R U&R DENTAL SERVICES Repair or replacement of each injured sound natural tooth damaged or lost as a result of a covered injury. Up to the dental maximum shown in the benefit schedule. Maximum per tooth $ PHYSIOTHERAPY 1. In Hospital following surgery U&R 80% of U&R 60% of U&R U&R 2. Outpatient following surgery U&R 80% of U&R 60% of U&R U&R 3. Outpatient no surgery Schedule Schedule Schedule Schedule A Division of Planned Benefit Services For information about the plan, call

5 Plans Starting as Low as $16 per Student/Student Athlete per Year

6 General Exclusions and Limitations This is only a general outline of exclusions. Services or treatment rendered by a physician, nurse, trainer, rehabilitation professional or any other person who is (a) employed, contracted, or retained by the school in advance of an injury or accident; or (b) who is the Plan Participant or a member of his/her immediate family. Intentionally self-inflicted injury, suicide while sane or insane and any attempt thereat. Committing or attempting to commit a felony, or being engaged in illegal activity. Participation in a riot or insurrection. An act of declared or undeclared war. Nuclear reactions or radiation contamination. Active duty in any Armed Forces of any country and, in such event, the pro-rata unearned premium will be returned upon proof of service. This does not include reserve or National Guard active duty or training unless it extends beyond 31 days. Sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, bacterial or viral infection, regardless of how contracted. This does not exclude bacterial infection that is the natural and foreseeable result of an injury. Cysts or skin lesions such as blisters or boils, hernia, regardless of how caused. Services or treatment rendered by a physician, nurse, or any other person who is: employed or retained by the Policyholder; or who is insured or a member of his immediate family. Flight in an aircraft, except as a fare paying passenger. Snow Skiing; scuba diving; bob-sledding; bungee jumping; ballooning; sky diving; hang-gliding; glider flying; sail-planing or parasailing. Working on or around any recreational vehicle. Travel in or upon: snowmobile; jet ski or ski cycle; any two or three wheeled motor vehicle; any four wheeled all-terrain vehicle (ATV); any off-road motorized vehicle not requiring licensing as a motor vehicle. Expenses incurred in excess of $500 to the extent that they are paid or payable under any automobile insurance policy without regard to fault. Any loss for which benefits are paid under state or federal worker s compensation, employer s liability, or occupational disease law. Injury caused by, contributed to or resulting from the insured s use of alcohol, illegal drugs or medicines that are not taken in the dosage or for the purpose as prescribed by the insured s Physician. Practice or play in any senior high interscholastic football; intercollegiate football; except where specified additional premium is paid. Travel directly to and from covered events or activities which is not approved, sponsored and supervised by a school official or in any vehicle which is not approved, sponsored, or supervised by a school official and driven by an approved properly licensed adult over 22 years of age. Activities not sponsored and supervised by the participant. Activities not sponsored by State High School Athletic/Activities Association or other Associations or Individual Entities and a member school (when Association holds group policy or master plan). Claim Filing Instructions The first expense must be incurred within 30 days after the date of the accident and result in treatment by a legally qualified physician. A participating school official must complete Part I of the Notification of Injury Form, keep a copy, and give the form to the parent or guardian. Parents must complete Part II of the Notification of Injury Form and submit to the claims payment office at the address shown on the form, within 90 days of injury. The parent or guardian is responsible for completing the form and submitting insurance carrier EOBs and bills from providers. Disclaimers Plan This is a plan overview and is not intended to provide a complete description of benefits covered. The Benefit Plans offered in each state contain exceptions, limitations and reductions. Plan and benefits availability vary by state. Underwriters of The Plans The Plan s Insurance Underwriters are A rated by Best. The Underwriting Insurance Carrier may vary by state. Licensed Insurance Agents The plan is available through State Licensed Insurance Agents in the applicable state. For claims, contact Preferred Health Alliance P.O. Box , Birmingham, AL TF A Division of Planned Benefit Services For information about the plan and its availability in your state, contact Planned Benefit Services, Inc. Managing General Agents 556 Clay Street, Montgomery, AL P TF F E info@plannedbenefit.com TeamAssure.net

VOLUNTARY STUDENT ACCIDENT INSURANCE COVERAGE For

VOLUNTARY STUDENT ACCIDENT INSURANCE COVERAGE For RIVERSIDE BEAVER COUNTY SCHOOL DISTRICT To help guard against the expense of an accident we are once again offering Voluntary Student Accident Insurance