Student Accident Only Insurance Plan ( the Plan )

Student Accident Only Insurance Plan ( the Plan ) Designed for all domestic students enrolled for classes at the Tennessee Colleges of Applied Technology 2013-2014 State University & Community College System of Tennessee ( the Policyholder ) Customer Service Questions : 1-888-722-1668 Email: ttc@studentinsurance.com www.studentinsurance.com Insurance underwritten by: National Union Fire Insurance Company of Pittsburgh, Pa., with its principal place of business in New York, NY (the Company ) Administrator Policy #CHH0086884 Underwriter Reference #CAS9495426 S30645NUFI

Tennessee Board of Regents Student Accident Only Insurance Plan 2013-2014 Table of Contents: Accidental Death&Dismemberment..5 Benefits Schedule.............4 Claim Procedures.............3 Contact Information..........12 Coordination of Benefits........3 Definitions................ 6-7 Effective and Termination Dates.. 2-3 Eligibility................... 2 Exclusions.................5-6 Plan Premiums...............3 ELIGIBILITY Each domestic student enrolled for classes at the Tennessee Colleges of Applied Technology is eligible for coverage under the Plan and may insure himself or herself by enrolling on the enrollment form provided by the school. If the student is enrolled at least half-time and is degree seeking, Internet/online classes fulfill the eligibility requirements. Home study, correspondence, and television (TV) courses do not fulfill the eligibility requirements. An eligible student must attend classes at the school for at least the first 31 days of the period for which he or she is enrolled. The Company maintains the right to investigate student status and attendance records to verify that the Plan eligibility requirements have been met. If it is discovered that the Plan eligibility requirements have not been met, the Company s only obligation is to refund premium. An eligible student may enroll for coverage for himself or herself only under the following conditions: (a) during an initial or subsequent open enrollment period*; or (b) as a transfer student, within 31 days of the date of transfer; or (c) upon experiencing ineligibility under another creditable plan and exhaustion of all available COBRA or continuation coverage. *The first 31 days of the fall, spring and summer semesters. EFFECTIVE AND TERMINATION DATES* The Master Policy becomes effective at 12:01 a.m. on September 2, 2013 and terminates at 11:59 p.m. on September 1, 2014. The coverage of an eligible student who enrolls for coverage under the Plan during an initial open enrollment period on or before the Plan effective date or who enrolls for coverage within 31 days of the date of transfer to the Policyholder, shall take effect at 12:01 a.m. on the latest of the following dates: (1) the Plan effective date; (2) the date for which the first premium for the Covered Student s coverage is paid; or (3) the date the Student becomes a member of an eligible class of persons as described in the Description of Class section of the Schedule of Benefits in the Policy on file with the Policyholder. The coverage of a student enrolled under the Plan during any subsequent open enrollment period shall take effect on the later of the following dates: (1) the date for which the premium for the Covered Student s coverage is paid; or (2) the date the Policyholder s term of coverage begins. Awesome tips on fitness, nutrition, health care and more. Check us out at www.studentinsurance.com 2 of 8

Tennessee Board of Regents Student Accident Only Insurance Plan 2013-2014 Effective and Termination Dates Continued... However, if enrollment for coverage under the Plan is made more than 30 days following the date the Eligible student becomes eligible, then his or her insurance will become effective only if and when the Company gives its written consent. Insurance for a Covered Student will end at 11:59 p.m. on the first of these to occur: (a) the date the Plan terminates; (b) the last day for which any required premium has been paid; or (c) the date on which the Covered Student withdraws from the school because of: (1) entering the armed forces of any country (premiums will be refunded on a pro-rata basis when written request is made within 90days of leaving school.); or (2) withdrawal from school during the first 31 days of the period for which enrollment was made. If withdrawal from school is for other than (1) or (2) above, no premium refund will be made. Students will be covered for the Plan term for which they are enrolled and for which premium has been paid. COORDINATION OF BENEFITS PROVISION Coordination of Benefits Provision: The Company will coordinate benefits with other health carriers when duplicate coverage exists. Total payment from this coverage and other health coverages under which the Covered Person is enrolled shall not exceed 100% of the R&C Charges for covered services. CLAIMS PROCEDURES 1. Written Notice of claim must be given to the Company within 90 days after the occurrence or commencement of any loss covered by the Policy, or as soon thereafter as is reasonably possible. To submit the written claim form go to www.studentinsurance.com, log into your account and click on student options. The claim form can be submitted online electronically. 2. In the event that a PPO Provider submits the Covered Person s claim(s), please be sure that the Provider photocopies the Covered Person s insurance card. 3. The Covered Person should retain one copy of all claims information submitted for his or her records. PAYMENT WILL BE MADE TO THE PROVIDERS OF SERVICE (Hospital, Doctor and others), UNLESS A PAID RECEIPT ACCOMPANIES THE BILL AT THE TIME THE CLAIM IS SUBMITTED. 2013-2014 STUDENT ACCIDENT ONLY INSURANCE PLAN PREMIUMS PLAN PREMIUMS Annual Fall Spring/Summer Summer* (*new students only) 9/02/13-9/01/14 9/02/13-1/01/14 1/02/14-9/01/14 5/01/14-9/01/14 Student Full-Time $110.00 $45.00 $89.00 $45.00 Student School-Time $57.00 $23.00 $46.00 $23.00 3 of 8

Tennessee Board of Regents Student Accident Only Insurance Plan 2013-2014 TENNESSEE BOR SCHEDULE OF BASIC MEDICAL EXPENSE BENEFITS - ACCIDENT When, by reason of Injury caused by Covered Accident, a Covered Person incurs Eligible Expenses for Hospital, surgical or medical treatment, services or supplies, the Company will pay the Reasonable & Customary charges for Eligible Expenses incurred. The benefits will be paid in accordance with the allocations shown below. The Company must receive proof that the Eligible Expenses were solely the result of an Injury sustained by the Covered Person and the first such Expense must be incurred within 30 days after the date of the Accident causing the Injury. The Company will pay for Eligible Expenses which are the direct result of the Accident, and from no other cause, within 365 days of the Accident. MAXIMUM BENEFIT INPATIENT Room and Board Expense, limited to the semi-private rate(except intensive care unit amount may not exceed 2½ times the Hospital Daily Room and Board) Miscellaneous Hospital Expense, includes expenses incurred for anesthesia and operating room; laboratory tests and X-rays; oxygen tent; drugs, medicines, dressings; and other Medically Necessary and prescribed. Surgeon s Fees, when Injury requires two or more surgical procedures when Injury requires two or more surgical procedures which are performed through the same approach, and at the same time or immediate succession, the Company will pay only for the most expensive procedure performed (subject to the maximum amount). Anesthesia Percentage Doctor s visits, (other than a Doctor who performed surgery or administered anesthesia) Pre-Admission Testing OUTPATIENT Surgeon s Fees, when Injury requires two or more surgical procedures which are performed through the same approach, and at the same time or immediate succession, the Company will pay only for the most expensive procedure performed (subject to the maximum amount). Anesthesia Percentage Day Surgery Facility/Miscellaneous, when related to scheduled surgery performed in a Hospital including: use of operating room; x-rays examinations and laboratory tests (including professional fees); anesthesia; infusion therapy; drugs or medicines; and supplies. Doctor s Visits (other than a Doctor who performed Surgery) Benefits are limited to one visit per day. Non-Surgical Only: Other outpatient services include: diagnostic X-ray, and laboratory services; radiation therapy and chemotherapy; physiotherapy (visits limited to one per day); injections (covered only in the Doctors office); diagnostic services and medical procedures performed by the Doctor (other than Doctor s visits, physiotherapy, x-rays and lab procedures; and braces and appliances only upon Doctor s written prescription; use of Hospital emergency room (only Medically Necessary and prescribed expense). OTHER Ambulance Expense Dental Treatment Expense $2,000 For Each Injury Up to a maximum of $200 per day for up to 10 days Up to a maximum of $500 per day $750 15% of amount payable for Surgery Up to a maximum of $25 per day (limited to one visit per day) Included in Miscellaneous Hospital Expense $750 15% of amount payable for Surgery $250 Up to a maximum $15 per visit, beginning with the second visit $500 $100 Up to $100 per tooth 4 of 8

Tennessee Board of Regents Student Injury Only Insurance Plan 2013-2014 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT Maximum Amount: $8,000 The Company will pay the benefit below for Injuries to a Covered Student: (a) caused by an Accident which happens while a student is covered by this Plan; and (b) which directly, and from no other cause, result in any of the losses listed below within 180 days of the Accident that caused the Injury. For Loss of Percentage of Maximum Amount Life...100% Both Hands or Both Feet...100% Sight of Both Eyes...100% One Hand and One Foot...100% One Hand and the Sight of One Eye...100% One Foot and the Sight of One Eye...100% One Hand or One Foot...50% The Sight of One Eye...50% Thumb and Index Finger of Same Hand...25% "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. Loss of thumb and index finger means complete severance through or above the metacarpophalangeal joint of both digits. Severance means the complete separation and dismemberment of the part from the body. If a Covered Student suffers more than one loss as a result of the same Accident, the Company will pay only for the loss with the largest benefit. EXCLUSIONS This Plan does not cover nor provide benefits for loss or expenses incurred: 1. as a result of dental treatment, or dental x-rays except for treatment resulting from Injury to sound natural teeth. 2. for services normally provided without charge by the Policyholder's Health Service, Infirmary or Hospital, or by health care providers employed by the Policyholder or services covered by the Student Health Center fee. 3. for eye examinations, eyeglasses, contact lenses, replacement of eyeglasses or prescription for such; radial keratotomy or laser surgery; hearing aids or prescriptions or examinations for such; or treatment for visual defects and problems. Visual defects means any physical defect of the eye which does or can impair normal vision apart from the disease process. 4. for 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 apart from the disease process. 5. as a result of an Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by a commercial scheduled airline. 6. for Injury resulting from war or act of war, declared or undeclared. 7. as a result of an Injury for which benefits are paid under any Workers' Compensation or Occupational Disease Law. 8. as a result of Injury sustained while in the service of the Armed Forces of any country. Upon the Covered Person entering the Armed Forces of any country, the Company will refund any unearned pro-rata premium. This does not include Reserve or National Guard Duty for training unless it exceeds 31 days. 9. for treatment provided in a government Hospital unless there is a legal obligation to pay such charges in the absence of insurance. 10. for Injuries sustained as the result of a motor vehicle Accident to the extent provided for any loss or any portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable. 11. as a result of committing or attempting to commit an assault or felony or participation in a felony, riot, illegal occupation, insurrection or civil commotion. 12. for any services rendered by a Covered Person s immediate family member. 5 of 8

Tennessee Board of Regents Student Injury Only Insurance Plan 2013-2014 Plan Exclusions Continued... 13. for a treatment, service or supply which is not Medically Necessary. 14. as a result of suicide or any attempt at suicide, including drug overdose or intentionally self-inflicted Injury or any attempt at intentionally self-inflicted Injury. 15. for outpatient prescription drugs. 16. beyond 365 days from the date of the Injury. 17. for Injury caused by, contributed to or resulting from the Covered Person s use of alcohol, illegal drugs or use of legal medicines that are not taken in the dosage or for the purpose as prescribed by the Covered Person s Doctor. 18. for orthopedic appliances or braces. 19. for surgery and/or treatment of: corns, calluses and bunions; deviated nasal septum, including submucuous resection and/or other surgical correction thereof; and hernia of any kind. 20. for Injury resulting from travel in or upon a snowmobile, ATV (all terrain or similar type two or three-wheeled vehicle), personal watercraft or bungee jumping. 21. for organ transplants. 22. for Injury resulting from: the practicing for, participating in, or traveling as a team member to and from interscholastic, intercollegiate, club, professional and semi-professional sports activity, including travel to and from the activity and practice; hang gliding; parasailing; sky diving; glider flying; sail planing; or parachuting. 23. for Injury resulting from fighting, except in self-defense. 24. for the services of an assistant surgeon. 25. for treatment, services, drugs, device, procedures or supplies that are experimental or investigational. 26. for treatment of sickness or disease in any form or mental derangement. DEFINITIONS "Accident" means an occurrence which (a) is unforeseen; (b) is not due to or contributed to by disease of any kind; and (c) causes Injury. "Covered Person" means a Covered Student while coverage under this Plan is in effect. "Covered Student" means a student of the Policyholder who is insured under this Plan. "Doctor" means: (a) legally qualified physician licensed by the state in which he or she practices; and (b) a practitioner of the healing arts performing services within the scope of his or her license as specified by the laws of the state of such practitioner; and (c) certified nurse midwives and licensed midwives while acting within the scope of that certification. The term Doctor does not include a Covered Person s immediate family member. "Eligible Expense" means a charge for any treatment, service or supply which is performed or given under the direction of a Doctor for the Medically Necessary treatment of an Injury: (a) not in excess of the Reasonable and Customary charges; or (b) not in excess of the charges that would have been made in the absence of this coverage; (c) is the negotiated rate, if any and (d) incurred while the Plan is in force as to the Covered Person. "Emergency Medical Condition" means a medical condition that manifests itself by symptoms of sufficient severity, including, severe pain, that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the person afflicted with such condition in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part of such person; (d) serious disfigurement of such person. Emergency Services means health care items and services furnished in a Hospital which are required to determine, evaluate and/or treat an emergency medical condition, until the condition is stabilized, as directed or ordered by a Doctor or directed by Doctor or Hospital protocol. 6 of 8

Tennessee Board of Regents Student Injury Only Insurance Plan 2013-2014 Definitions Continued... Injury means bodily injury due to an Accident which: (a) results solely, directly and independently of disease, bodily infirmity or any other causes; (b) occurs after the Covered Person s effective date of coverage; and (c) occurs while coverage is in force. All injuries sustained in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered one Injury. Medical Necessity/Medically Necessary" means that a drug, device, procedure, service or supply is necessary and appropriate for the diagnosis or treatment of an Injury based on generally accepted current medical practice in the United States at the time it is provided. A service or supply will not be considered as Medically Necessary if: (a) it is provided only as a convenience to the Covered Person or provider; or (b) it is not the appropriate treatment for the Covered Person's diagnosis or symptoms; or (c) it exceeds (in scope, duration or intensity) that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment; or (d) it is experimental/investigational or for research purposes; or (e) could have been omitted without adversely affecting the patient s condition or the quality of medical care; or (f) involves treatment of or the use of a medical device, drug or substance not formally approved by the U.S. Food and Drug Administration (FDA); or (g) involves a service, supply or drug not considered reasonable and necessary by the Center for Medicare and Medicaid Services Issues Manual; or (h) it can be safely provided to the patient on a more cost-effective basis such as outpatient, by a different medical professional or pursuant to a more conservative form of treatment. The fact that any particular Doctor may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service or supply Medically Necessary. Pre-Existing Condition means an Injury, regardless of the cause, for which medical care, treatment, diagnosis or advice was received or recommended within the 6 months prior to the Covered Person s effective date of coverage under the Plan. "Reasonable and Customary" means the charge, fee or expense which is the smallest of: (a) the actual charge; (b) the charge usually made for a covered service by the provider who furnishes it; (c) the negotiated rate, if any; and (d) the prevailing charge made for a covered service in the geographic area by those of similar professional standing. PRE-EXISTING CONDITIONS Expenses incurred by a Covered Person as a result of a Pre-existing Condition will not be considered Eligible Expenses unless no charges are incurred or treatment rendered for the condition for a period of twelve months of continuous coverage while covered under this Plan. This limitation will not apply if, during the period immediately preceding the Covered Person s effective date of coverage under this Plan, the Covered Person was covered under prior creditable coverage for twelve consecutive months. Prior creditable coverage of less than twelve months will be credited toward satisfying the Pre-existing Condition limitation. This waiver of Pre-existing Condition limitation will apply only if the Covered Person becomes eligible and enrolls for coverage within 63 days of termination of his or her prior coverage. Awesome tips on fitness, nutrition, health care and more. Check us out at www.studentinsurance.com 7 of 8

Tennessee Board of Regents Student Injury Only Insurance Plan 2013-2014 CLAIMS ADDRESS: AIG, Educational Markets Mail Center P.O. Box 26050 Overland Park, KS 66225 CLAIMS QUESTIONS: AIG, Educational Markets Toll Free: 1-888-722-1668 STUDENT HEALTH INSURANCE Website: www.studentinsurance.com E-mail: ttc@studentinsurance.com The Policy is non-renewable one year term insurance. Similar coverage may be purchased for the following academic year. It is the Covered Student s responsibility to maintain continuity of coverage by inquiring about such coverage if he or she has not received the information for the new Policy Year. IMPORTANT INFORMATION This brochure is a general summary of the insurance. This is only a brief description of the coverage available under policy series S30494NUFIC-TN. The Policy is on file and available for review at the University. The Policy may contain definitions, reductions, limitations, exclusions and termination provisions not included in this brochure. Full details of the coverage are contained in the Policy. If there is any conflict between the contents of this brochure and the Policy, the Policy shall govern. This Plan also covers Mandated Benefits as required by the State of Tennessee. Insurance and services provided by member companies of American International Group, Inc. Coverage may not be available in all jurisdictions and is subject to actual policy language. For additional information, please visit our website at www.aig.com.