Student Accident & Sickness Insurance Plan 2013-2014 SAINT AUGUSTINE S UNIVERSITY Saint Augustine s University Accident Policy #BSA-00179 Student Insurance Information Site: www.saustudent Insurance.com This brochure is a brief description of the Student Health Insurance Plan. The exact provisions governing the insurance are contained in the Policy issued to the College. Any provision of this Plan which, on its effective date, is in conflict with the statutes of the State in which it is issued, is hereby amended to conform to the maximum requirements of such statutes. Policy underwritten by BCS Insurance Company, Oakbrook Terrace, Illinois Saint Augustine's University Student Accident Insurance Identification Card BCS Insurance Company NOTE: In a life threatening emergency, go to the nearest emergency room for treatment. BSA-00179 Notification of Injury or Sickness must be provided to the Company within 90 days after the date of accident or the commencement of Sickness. Bills for which benefit is to be paid must be submitted within 180 days of the date of treatment. SCAN for a direct link to your student insurance website.
TABLE OF CONTENTS STUDENT INSURANCE..........................................................................................3 MANDATORY 24 HOUR ACCIDENT ONLY........................................................................3 ELIGIBILITY....................................................................................................3 BASIC ACCIDENT BENEFITS.....................................................................................3 INTERCOLLEGIATE SPORTS.....................................................................................3 ACCIDENT BENEFIT............................................................................................3 ACCIDENTAL DEATH AND DISMEMBERMENT...................................................................3 ACCIDENT DEFINITIONS........................................................................................3 ACCIDENT EXCLUSIONS........................................................................................4 EXCESS PROVISION.............................................................................................4 DENTAL, VISION, AND PHARMACY OPTIONS....................................................................5 NOTICE OF PRIVACY PRACTICE.................................................................................5 HOW DO I OBTAIN MY IDENTIFICATION CARD?.................................................................5 HOW CAN I RECEIVE ASSISTANCE WITH A QUESTION OR PROBLEM?.............................................5 ADDITIONAL INFORMATION...................................................................................5
STUdENT INSUrANCE mandatory 24 HOUr ACCIdENT ONLy This plan protects students of Saint Augustine s University at home, at school or while traveling, 24 hours a day for 12 months. 1. This insurance becomes effective at 12:00 a.m. on the latter of August 1, 2013 or date of application and the payment of premium and continues until 11:59 a.m. on the earlier of the date to which the premium is paid or through July 31, 2014. 2. Protection is in effect during all vacation periods. 3. All school sponsored activities are covered 4. Coverage remains in force even if you may leave school. Refunds are made only in the event of entry into the armed forces. ELIgIBILITy All full time students are automatically enrolled in the Mandatory 24 Hour Accident Only Basic Benefits. The Company maintains the right to investigate student status and attendance records to verify that policy eligibil ity requirements have been met. If the Company discovers that the policy eligibility requirements have not been met, the Company s only obligation is refund of premium. Eligibility requirements must be met each time a premium is paid to continue coverage. BASIC ACCIdENT BENEFITS We will pay Covered Charges when your Injury requires: a) treatment by a Doctor; b) Hospital Confinement; c) services of a licensed practical nurse or R.N., d) X ray service; e) use of operating room, anesthesia, laboratory services; f) use of an ambulance; g) use of an Ambulatory Surgical Center or Ambulatory Medical Center; h) if ordered by a Doctor, prescription medicines, drugs, or any other therapeutic services or supplies; i) Home Health Care. We will pay 100% of the Covered Charges in excess of the first $50 incurred within fifty two (52) weeks after the date of accident up to a maximum of $5,000. This benefit includes coverage for treatment of Injury to sound, natural teeth. INTErCOLLEgIATE SPOrTS ACCIdENT BENEFIT Policy effective date is August 1, 2013 to August 1, 2014. Intercollegiate Sports Accident Benefit: We will pay Covered Charges when your Injury requires: a) treatment by a Doctor; b) Hospital Confinement; c) services of a licensed practical nurse or R.N.; d) X ray services; e) use of operating room, anesthesia, laboratory services; f) use of an ambulance; g) use of an Ambulatory Surgical Center or Ambulatory Medical Center; h) if ordered by a Doctor, prescription medicines, drugs, or any other therapeutic services or supplies; i) Home Health Care. We will pay 100% of the Covered Charges incurred within one hundred four (104) weeks after the date of accident up to a maximum of $90,000. This benefit includes coverage for treatment of Injury to sound, natural teeth. ACCIdENTAL death ANd dismemberment If, within 365 days from the date of an Injury, including an Injury sustained as a result of participation in intercollegiate sports, which occurs while coverage is in force, Injury from such accident results in loss covered by this benefit, We will pay the benefit in the amount set opposite such loss, as shown below. For loss of: Amount Life $2,000 Both hands or both feet or sight of both eyes $2,000 One hand and one foot $2,000 One hand and sight of one eye $2,000 One foot and sight of one eye $2,000 One hand or one foot or sight of one eye $1,000 The most we will pay for all losses as the result of one accident is $2,000. Loss of hands and feet means severed at or above the wrist or ankle joints. Loss of sight means total and irrecoverable loss of sight. ACCIdENT definitions Accident means a sudden, unexpected and unintended incident Covered Accident means an Accident that results in Injury or loss covered by this Policy. Covered Charge means the reasonable and customary charges incurred for a service or supply which is performed or given at the direction of a Doctor for the medically necessary treatment of a Sickness or Injury. A Covered Charge is considered incurred on the date the treatment or service is rendered or the supply is furnished. Covered Person means any Eligible Person and, where applicable, Eligible Dependents who make application for, or for whom application is made and who is approved to participate in the benefit plans issued under this Policy, provided the required premium for such Person s insurance is paid when due. Hospital means a legally constituted institution having organized facilities for the care and Treatment of sick or injured persons on a registered Inpatient basis, including facilities for diagnosis and surgery under the supervision of a staff of one or more licensed Physicians and provides 24 hour nursing service by Registered Nurses on duty or call. Hospital shall also include duly licensed tax supported institutions which specialize in the treatment of one particular type of illness. Such facilities are not required to have an operating room and related equipment for the performance of surgery. Injury means accidental bodily harm sustained by the Covered Person that resulted directly and independently of all other causes from an Accident and occurs while coverage under this Policy is in force. Physician means a practitioner of the healing arts who is duly licensed in the state where he is practicing and who is treating within the scope and limitation of the license. the term Physician will not include the Covered person or his spouse, children, brothers, sisters, or parents, or any person residing in his household. 3
definitions (CONTINUEd) Sickness means illness or disease contracted and causing loss as to the Covered person whose Sickness is the basis of claim. Any complications or any condition arising out of a Sickness for which the Covered Person is being treated or has received Treatment will be considered as part of the original Sickness. ACCIdENT EXCLUSIONS Benefits are not payable under this Policy for any of the following or loss that results therefrom: Routine physical examinations and routine testing; preventative testing or Treatment; screening exam inations or testing in the absence of Injury. Eye examinations; prescriptions or fitting of eyeglasses and contact lenses or other Treatment for visual defects and problems, except as required as a result of a covered Injury. Visual defects means any physical defect of the eye that does or can impair normal vision. Hearing examinations or hearing aids; or other Treatment for hearing defects and problems, except as required as a result of a covered Injury. Hearing defects means any physical defect of the ear that does or can impair normal hearing. War or any act of war, declared or undeclared; or while serving in the armed forces of any country (pro rated premium will be refunded for such period of service). Participation in a riot or civil disorder; fighting or brawling, except in self defense; commission of or attempt to commit a felony. Suicide, attempted suicide or intentionally self inflicted Injury while sane or insane. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planning, bungee jumping, or flight in any type of aircraft, except while riding as a fare paying passenger on a regularly scheduled airline. Treatment, services or supplies provided by a Hospital or facility owned or run by the United States Government, unless a charge is made for such services in the absence of insurance; or in a Hospital which does not unconditionally require payment. Elective Treatments and voluntary testing. Injury or Sickness covered by Worker s Compensation or Employer s Liability Laws. Treatment or services provided by any member of the Covered Person s immediate family; or for which no charge is normally made. Treatment, services or supplies provided by the School s infirmary or its employees, or Physicians who work for the School, except when the Covered person is required to pay for such service. Organ transplants. Mental or Nervous Disorders, except as specifically mentioned. Elective abortions Outpatient Prescriptions Drugs Participation in, practice for, or orthopedic equipment and appliances used for: professional sports or semiprofessional sports. ACCIdENT EXCLUSIONS (CONTINUEd) Cosmetic surgery, except cosmetic surgery which the Covered Person needs as the result of an Accident which happens while he is insured under this Policy. Nasal or Sinus Surgery unless required due to an injury resulting from an Accident while the Covered Person is insured under this Policy. Acupuncture. Outpatient treatment for Physiotherapy, except for a condition that required surgery or Hospital confinement immediately preceding such physiotherapy or within 30 days of the Physician s release for rehabilitation from such Hospital. The diagnosis and treatment of acne. The diagnosis and treatment of Infertility. Supplies, except as otherwise provided In the Policy. Treatment of allergies. Including allergy testing. Routine foot care, including the treatment of corns, calluses arid bunions. Impotence, whether organic or otherwise. Nonmalignant warts, moles, or lesions. Sleeping disorders. including testing thereof. EXCESS PrOvISION (APPLIES ONLY TO BASIC ACCIDENT AND INTERCOLLEGIATE SPORTS COVERAGE) The Company's liability for benefits due to Covered Expenses incurred for Treatments and services resulting from a covered Injury will be limited in the manner shown on the Schedule of Benefits. When a Covered Expense is subject to this Excess Provision, the Company's liability is limited to that part of the Expense, if any, which is in excess of the total benefits payable for the same loss, on a provision of service basis or on an expense incurred basis under any other collectible policy or service contract, unless otherwise herein provided. 4
AddITIONAL INFOrmATION dental, vision, ANd PHArmACy OPTIONS Please call (800) 452 5772 to request a brochure or visit our web site at: and click on Dental and Vision section at the bottom of the website. NOTICE OF PrIvACy PrACTICE This describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully at: HOW do I OBTAIN my IdENTIFICATION CArd? 1. You may detach and retain the Identification Card provided on the brochure. 2. You may obtain your Identification Card on the Internet at:. Click on Print ID Card. You will need to provide your name, student identification number, and your birth date. If you experience any difficulty, please call us at (800) 452 5772. 3. You may call (800) 452 5772 and request that your Identification Card be mailed to you. ImPOrTANT: Written notice of claim must be provided within 90 days after the occurrence, or commencement of any loss covered by the policy. Bills for which benefits are to be paid must be submitted within 180 days of the date of treatment. 4. Any additional medical bills submitted for reimbursement by the Insurance Company must show your name, student identification number, name of college or university, and description of medical condition. Only one claim form, per condition, needs to be completed. HOW CAN I receive ASSISTANCE WITH A QUESTION Or PrOBLEm? Please call the Administrator, at (800) 452 5772, Monday through Friday, between the hours of 9:00 a.m. to 5:00 p.m. Central Standard Time, or email us through the Insurance Information Internet Site:. We appreciate hearing from you with your comments, questions, and concerns. HOW do I FILE my CLAIm UNdEr my STUdENT INSUrANCE PLAN? 1. Secure the necessary medical treatment. Pre-Certification is not required. 2. Obtain itemized bills from your physician or provider. 3. Complete a claim form. A claim form is available at. If your pro vider has already mailed the bills to the Insurance Company, you may complete the claim form and email it to the Insurance Company. If you have not yet mailed the medical bills, print a claim form, complete it, and mail the completed claim form along with your medical bills to: Administrative Concepts, Inc. 994 Old Eagle School road Suite 1005 Wayne, PA 19087-1802 800-452-5772 7