2013-202838-1 intrax participant-v12_benefit summary

International Injury and Sickness
Insurance Plan for
Intrax Participants
Intrax SP is pleased to offer an Injury and Sickness Insurance Plan underwritten by Student Resources (SPC) Ltd. All eligible participants are automatically enrolled on a mandatory basis.
Student Resources (SPC) Ltd., aUnitedHealth Group Company, Highlights of the Coverage and Services
offered by Student Resources (SPC) Ltd. are:
Up to $100,000 Maximum Benefit for each Injury or Sickness for Covered Medical Expenses.
Covered Medical Expenses for Preferred Providers are payable at 100% of Preferred Allowance and Out of Network benefits are payable at 100% of Usual and Customary charges (all benefits are subject to satisfaction of the Deductible, specific benefit limitations, maximums and Copays as described in the policy).
Prescription Drug Benefits: 100% of Usual and Customary Charges.
U.S. citizens are not eligible for this insurance coverage as an Insured or a Dependent.
Coverage available for eligible Dependents, including Domestic Partners.
The Preferred Provider Network for this plan is UnitedHealthcare Options PPO. Preferred Providers can be found using the following link, http://www.uhcsr.com/lookupredirect.aspx?delsys=01 FrontierMEDEX – International Participants are covered worldwide except in their home Online Services: Student Resource (SPC) Ltd. Insureds have online access to their claims status, EOBs, ID Cards, network providers, correspondence and coverage account information by logging in to My Account at www.uhcsr.com/myaccount. To create an online account, select the “create My Account Now” link and follow the simple, onscreen directions. All you need is your 7-digit Insurance ID number or the email address on file. Insureds can also visit our mobile site at my.uhcsr.com to access an electronic ID card.
PRE-EXISTING CONDITION means: 1) the existence of symptoms which would cause an
ordinarily prudent person to seek diagnosis, care or treatment within the 12 months immediately
prior to the Insured's Effective Date under the policy; or, 2) any condition which originates, is diagnosed, treated or recommended for treatment within the 12 months immediately prior to theInsured's Effective Date under the policy.
The policy contains all of theprovisions, limitations, exclusions,and qualifications of your insurancePlan.
Travel Benefits and Personal Liability*
All Coverages and Benefits are in U.S. Dollar Amounts.
$3,000 - Maximum Benefit per article $500 combined Maximum $1,000 forjewelry, furs, watches, personal computers, cameras Liability
*Travel Benefits and Personal Liability are provided to all Insureds enrolled in this Plan. These plans are underwritten by Lloyds
of London.
BAGGAGE/PERSONAL EFFECTS
We will pay for loss, theft or damage to baggage and personal effects that accompany You on Your Trip. This coverage is secondaryto any other coverage.
TRIP INTERRUPTION
We will pay to return You Home if a Family Member suffers a life-threatening Sickness, Accidental Injury or death. All transportationin connection with a Trip Interruption must be pre-approved and arranged by the assistance provider.
PERSONAL LIABILITY
We will pay on Your behalf all sums that You become legally obligated to pay as the result of Damages from an Incident that wasreported during the Policy Term. Incident means any act or omission committed by You during the Policy Term which unexpectedly,unintentionally, and suddenly results in Bodily Injury, Property Damage or Personal Injury to a third party. Please note the above is just a summary of benefits and is not Your final fulfillment document. Please refer to
www.uhcsr.com/intrax for a complete copy of the terms and conditions including any exclusions that apply to each benefit.
EXCLUSIONS AND LIMITATIONS:
No benefits will be paid for: a) loss or expense caused by, contributed to, or 36. Nuclear, chemical or biological Contamination, whether direct or resulting from; or b) treatment, services or supplies for, at, or related to any indirect. “Contamination” means the contamination or poisoning of people by nuclear and/or chemical and/or biological substances 37. Organ transplants, including organ donation; 38. Orthoptics, visual therapy or visual eye training; 4. Addiction, such as: nicotine addiction; and caffeine addiction; non- 39. Outpatient Physiotherapy; except for a condition that required surgery chemical addiction, such as: gambling, sexual, spending, shopping, or Hospital Confinement: 1) within the 90 days immediately preceding such Physiotherapy; or 2) within the 90 days immediately following the 5. Autistic disease of childhood, hyperkinetic syndromes, milieu therapy, attending Physician's release for rehabilitation; learning disabilities, behavioral problems, intensive behavioral 40. Participation in a riot or civil disorder; commission of or attempt to therapies, such as applied behavioral analysis; parent-child problems, attention deficit disorder, conceptual handicap, developmental delay 42. Prescription Drugs, services or supplies as follows: a) Therapeutic devices or appliances, including: hypodermic 7. Charges and all costs related to or arising from or in connection with needles, syringes, support garments and other non-medical all trips to the host country undertaken for the purpose of securing substances, regardless of intended use, except as specifically b) Birth control and/or contraceptives, oral or other, whether medication or device, regardless of intended use; c) Immunization agents, biological sera, blood or blood products 12. Cosmetic procedures, except cosmetic surgery required to correct an d) Drugs labeled, “Caution - limited by federal law to investigational Injury for which benefits are otherwise payable under this policy; 13. Custodial Care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, or places mainly for domiciliary or Drugs used to treat or cure baldness; anabolic steroids used for Custodial Care; extended care in treatment or substance abuse facilities for domiciliary or Custodial Care; g) Anorectics - drugs used for the purpose of weight control; 14. Dental treatment, as specifically provided in the Schedule of Benefits; h) Fertility agents or sexual enhancement drugs, such as Parlodel, 15. Elective Surgery or Elective Treatment; Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; 16. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects and problems; Refills in excess of the number specified or dispensed after one except when due to a covered Injury or disease process; (1) year of date of the prescription.
17. Flat foot conditions; supportive devices for the foot; subluxations of the 43. Reproductive/Infertility services including but not limited to: family foot; fallen arches; weak feet; chronic foot strain; symptomatic planning; fertility tests; infertility (male or female), including any services complaints of the feet; and routine foot care including the care, cutting or supplies rendered for the purpose or with the intent of inducing and removal of corns, calluses, toenails, and bunions (except capsular conception; premarital examinations; impotence, organic or otherwise; female sterilization procedures; vasectomy; sexual reassignment 18. Genetic medicine or genetic testing, including without limitation surgery; reversal of sterilization procedures; amniocentesis, genetic screening, risk assessment, prevention and/or 44. Research or examinations relating to research studies, or any to determine pre-disposition, genetic counseling, and/or gene therapy; treatment for which the patient or the patient’s representative must 19. Health spa or similar facilities; strengthening programs; sign an informed consent document identifying the treatment in which 20. Hearing examinations; hearing aids; cochlear implants; or other the patient is to participate as a research study or clinical research treatment for hearing defects and problems, except as a result of an infection or trauma. "Hearing defects" means any physical defect of 45. Routine Newborn Infant Care, well-baby nursery and related Physician the ear which does or can impair normal hearing, apart from the 46. Preventive care services; routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in 22. HIV, AIDS Virus, AIDS related Sickness, ARC Syndrome, and AIDS, including any testing for these conditions and any Sickness arising as 47. Services provided normally without charge by the Health Service of 48. Skeletal irregularities of one or both jaws, including orthognathia and 24. Immunizations; preventive medicines or vaccines, except where mandibular retrognathia; temporomandibular joint dysfunction; required for treatment of a covered Injury; deviated nasal septum, including submucous resection and/or other 25. Injury caused by, contributed to, or resulting from, the addiction to or surgical correction thereof; nasal and sinus surgery, except for use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs treatment of a covered Injury or treatment of chronic purulent sinusitis; or medicines that are not taken in the recommended dosage or for the 49. Parachuting, hang gliding, glider flying, parasailing, sail planing, or flight purpose prescribed by the Insured Person's Physician; in any kind of aircraft, except while riding as a passenger on a regularly 26. Injury or Sickness for which benefits are paid or payable under any scheduled flight of a commercial airline; Workers' Compensation or Occupational Disease Law or Act, or 51. Speech therapy; naturopathic services; 27. Injury or Sickness inside the Insured’s home country; 52. Suicide or attempted suicide while sane or insane (including drug 28. Injury or Sickness outside the United States and its possessions, overdose); or intentionally self-inflicted Injury; except when traveling for academic study abroad programs to or from 53. Supplies, except as specifically provided in the policy; 54. Surgical breast reduction, breast augmentation, breast implants or 29. Injury or Sickness when claims payment and/or coverage is prohibited breast prosthetic devices, or gynecomastia 55. Treatment in a Government hospital, unless there is a legal obligation 30. Injury sustained while (a) participating in any intercollegiate, or for the Insured Person to pay for such treatment; professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c) while participatingin any practice or conditioning program for such sport, contest or 57. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded uponrequest for such period not covered); and 58. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat, and treatment of eating disorders such as bulimia and anorexia.
34. Maternity; pregnancy; and Complications of Pregnancy; INTERNATIONALINJURY AND SICKNESSINSURANCE PLAN Underwritten by Student Resources (SPC) Ltd.
Table of Contents
Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Accidental Death and Dismemberment Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11FrontierMEDEX: Global Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15ID Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back Cover Eligibility
All eligible participants are automatically enrolled in this insurance Plan.
The Company maintains its right to investigate Eligibility or participant status to verify thatthe policy Eligibility requirements have been met. If the Company discovers that the policyEligibility requirements have not been met, its only obligation is to refund premium.
Eligible participants who do enroll may also insure their Dependents. Eligible Dependentsare the spouse (husband or wife) or Domestic Partner and dependent children under 19years of age. See the Definitions section of the Brochure for the specific requirementsneeded to meet Domestic Partner eligibility. Dependent eligibility expires concurrently with that of the Insured participant.
U.S. citizens are not eligible for coverage as a participant or a Dependent.
Effective and Termination Dates
The Master Policy becomes effective at 12:01 a.m., January 1, 2014. The individualparticipant’s coverage becomes effective on the first day of the period for which premiumis paid or the date the enrollment form and full premium are received by the Company (orits authorized representative), whichever is later. The Master Policy terminates at11:59 p.m., December 31, 2014. Coverage terminates on that date or at the endof the period through which premium is paid, whichever is earlier. Dependent coveragewill not be effective prior to that of the Insured participant or extend beyond that of theInsured participant. Refunds of premiums are allowed only upon entry into the armedforces.
The Policy is a Non-Renewable Term Policy. Extension of Benefits After Termination
The coverage provided under the Policy ceases on the Termination Date. However, if anInsured is Hospital Confined on the Termination Date from a covered Injury or Sickness forwhich benefits were paid before the Termination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long as the condition continues but not toexceed 90 days after the Termination Date.
The total payments made in respect of the Insured for such condition both before and afterthe Termination Date will never exceed the Maximum Benefit. After this “Extension ofBenefits” provision has been exhausted, all benefits cease to exist, and under nocircumstances will further payments be made.
Pre-Admission Notification
UnitedHealthcare should be notified of all Hospital Confinements prior to admission.
1. Pre-Notification of Medical Non-Emergency Hospitalizations: The patient,
Physician or Hospital should telephone 1-877-295-0720 at least five working daysprior to the planned admission.
2. Notification of Medical Emergency Admissions: The patient, patient’s
representative, Physician or Hospital should telephone 1-877-295-0720 within twoworking days of the admission to provide notification of any admission due toMedical Emergency.
UnitedHealthcare is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m.
C.S.T., Monday through Friday. Calls may be left on the Customer Service Department’s voice
mail after hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise
payable under the policy; however, pre-notification is not a guarantee that benefits will be
paid.
Schedule of Medical Expense Benefits
Injury and Sickness
Up To $100,000 Maximum Benefit (For Each Injury or Sickness)
Paid as specified below
Deductible $0
Coinsurance Preferred Provider: 100% except as noted below
Coinsurance Out-of-Network: 100% except as noted below
The Preferred Provider for this plan is UnitedHealthcare Options PPO.
If care is received from a Preferred Provider, any Covered Medical Expenses will be paid atthe Preferred Provider level of benefits. If the Covered Medical Expense is incurred due toa Medical Emergency, benefits will be paid at the Preferred Provider level of benefits.
The Policy provides benefits for the Covered Medical Expense incurred by an InsuredPerson for loss due to a covered Injury or Sickness up to the Maximum Benefit of $100,000for each Injury or Sickness.
Benefits are subject to the policy Maximum Benefit unless otherwise specifically stated.
Benefits will be paid up to the maximum benefit for each service as scheduled below. Allbenefit maximums are combined Preferred Provider and Out-of-Network unless otherwisespecifically stated. Covered Medical Expenses include: Preferred
Out-of-Network
INPATIENT
Providers
Providers
Room & Board Expense, daily semi-private
room rate when confined as an Inpatient; generalnursing care provided by the Hospital.
Hospital Miscellaneous Expenses, daily semi-
private room rate when confined as an Inpatient;general nursing care provided by the Hospital.
Hospital Miscellaneous Expenses such as thecost of the operating room, laboratory tests, x-rayexaminations, anesthesia, drugs (excluding takehome drugs) or medicines, therapeutic services,and supplies. In computing the number of dayspayable under this benefit, the date of admissionwill be counted, but not the date of discharge.
Routine Newborn Care
Intensive Care
Physiotherapy
Surgeon’s Fees, if two or more procedures are
performed through the same incision or inimmediate succession at the same operativesession, the maximum amount paid will notexceed 50% of the second procedure and 50%of all subsequent procedures.
Preferred
Out-of-Network
INPATIENT
Providers
Providers
Assistant Surgeon
Anesthetist,
Registered Nurse’s Services, private duty
Physician’s Visits, non-surgical services when
confined as an Inpatient. Benefits do not applywhen related to surgery.
Pre-Admission Testing, payable within 3
OUTPATIENT
Surgeon’s Fees, if two or more procedures are
performed through the same incision or inimmediate succession at the same operativesession, the maximum amount paid will notexceed 50% of the second procedure and 50%of all subsequent procedures.
Day Surgery Miscellaneous, related to
scheduled surgery performed in a Hospital,including the cost of the operating room;laboratory tests and x-ray examinations, includingprofessional fees; anesthesia; drugs or medicines;and supplies. Usual and Customary Charges forDay Surgery Miscellaneous are based on theOutpatient Surgical Facility Charge Index.
Assistant Surgeon
Anesthetist, professional services administered
in connection with outpatient surgery.
Physician’s Visits, benefits for Physician’s
Visits do not apply when related to surgery orPhysiotherapy.
Physiotherapy, see exclusion number 39 for
additional limitations. Physiotherapy includes butis not limited to the following: 1) physicaltherapy; 2) occupational therapy; 3) cardiacrehabilitation therapy; 4) manipulative treatment;and 5) speech therapy, unless excluded in thepolicy.
($2,500 maximum Per Policy Year) Preferred
Out-of-Network
OUTPATIENT
Providers
Providers
Medical Emergency Expenses, facility charge for
use of the emergency room and supplies.
Treatment must be rendered within 72 hours from time of Injury or first onset of Sickness.
(The Copay/per service Deductible will be waived ifadmitted.) (The Copay/per service Deductible doesnot apply to Injury.) Diagnostic X-ray Services
Radiation Therapy
Laboratory Services
Tests and Procedures, diagnostic services and
medical procedures performed by a Physician,other than Physician’s Visits, Physiotherapy, x-rays and lab procedures. The followingtherapies will be paid under this benefit:inhalation therapy, infusion therapy, pulmonarytherapy and respiratory therapy.
Injections, when administered in the Physician's
office and charged on the Physician's statement.
Chemotherapy
Prescription Drugs
Ambulance Services
Durable Medical Equipment,
prescription must accompany the claim whensubmitted. Benefits are limited to the initialpurchase or one replacement purchase per PolicyYear. Durable Medical Equipment includes externalprosthetic devices that replace a limb or body partbut does not include any device that is fullyimplanted into the body.
Consultant Physician Fees, when requested and
approved by the attending Physician.
Dental Treatment, Benefits are limited to Injury to
Sound, Natural Teeth and emergency treatment foralleviation of sudden and unexpected pain relatedto an infection of the gum or Sound, Natural Teeth.
Emergency treatment does not include routinedental exams, pre-existing conditions includingcaries/cavities, restorative work, orthodontics,dental equipment, crown build up, crowns,reconstructive work or all other treatmentsunrelated to pain alleviation. ($200 maximum per tooth) Preferred
Out-of-Network
Providers
Providers
Maternity
Elective Abortion
Complications of Pregnancy
Mental Illness Treatment, services received on
an Inpatient and outpatient basis.
($500 maximum Per Policy Year) Substance Use Disorder Treatment
Diabetes Services
Reconstructive Breast Surgery Following
Mastectomy, in connection with a covered
mastectomy for:1) all stages of reconstruction of
the breast on which the mastectomy has been
performed; 2) surgery and reconstruction of the
other breast to produce a symmetrical appearance;
and 3) prostheses and physical complications of
mastectomy, including lymphedemas.
Home Health Care, services received from a
licensed home health agency that are ordered by aPhysician, provided or supervised by a RegisteredNurse in the Insured Person’s home, and pursuant to ahome health plan. Skilled Nursing Facility, services received while
confined as a full-time Inpatient in a licensedSkilled Nursing Facility in lieu of or within 24 hoursfollowing a Hospital Confinement. Preferred Provider Information
“Preferred Providers” are the Physicians, Hospitals and other health care providers who
have contracted to provide specific medical care at negotiated prices. Preferred Providers
in the local area are:
The availability of specific providers is subject to change without notice. Insureds should
always confirm that a Preferred Provider is participating at the time services are required by
calling the Company at 1-866-548-8472 and/or by asking the provider when making an
appointment for services. You can also locate a network provider by logging into My
Account at www.uhcsr.com.
“Preferred Allowance” means the amount a Preferred Provider will accept as payment
in full for Covered Medical Expenses.
“Out-of-Network” providers have not agreed to any prearranged fee schedules. Insureds
may incur significant out-of-pocket expenses with these providers. Charges in excess of the
insurance payment are the Insured’s responsibility.
Inpatient Expenses
PREFERRED PROVIDERS – Eligible Inpatient expenses at a Preferred Provider will be
paid at the Coinsurance percentages specified in the Schedule of Benefits, up to any limits
specified in the Schedule of Benefits. Call 1-866-548-8472 for information about
Preferred Hospitals.
OUT-OF-NETWORK PROVIDERS - If Inpatient care is not provided at a Preferred
Provider, eligible Inpatient expenses will be paid according to the benefit limits in the
Schedule of Benefits.
Outpatient Hospital Expenses
Preferred Providers may discount bills for outpatient Hospital expenses. Benefits are paid
according to the Schedule of Benefits. Insureds are responsible for any amounts that
exceed the benefits shown in the Schedule, up to the Preferred Allowance.
Professional & Other Expenses
Benefits for Covered Medical Expenses provided by UnitedHealthcare Options PPO will bepaid at the Coinsurance percentages specified in the Schedule of Benefits or up to anylimits specified in the Schedule of Benefits. All other providers will be paid according to thebenefit limits in the Schedule of Benefits.
Accidental Death and Dismemberment Benefits
Loss of Life, Limb or Sight
If such Injury shall independently of all other causes and within 180 days from the date of
Injury solely result in any one of the following specific losses, the Insured Person or
beneficiary may request the Company to pay the applicable amount below in addition to
payment under the Medical Expense Benefits provision.
For Loss Of:
Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or armsand feet or legs, dismemberment by severance at or above the wrist or ankle joint; withregard to eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater)resulting from any one Injury will be paid.
Excess Provision
Even if you have other insurance, the Plan may cover unpaid balances, Deductibles and pay
those eligible medical expenses not covered by other insurance, or under an automobile
insurance policy. Benefits will be paid on the unpaid balances after your other insurance has
paid.
No benefits are payable for any expense incurred for Injury or Sickness which has been paid
or is payable by other valid and collectible insurance or under an automobile insurance
policy.
However, this Excess Provision will not be applied to the first $100 of medical expenses
incurred.
Covered Medical Expenses excludes amounts not covered by the primary carrier due to
penalties imposed as a result of the Insured’s failure to comply with policy provisions or
requirements.
Important: The Excess Provision has no practical application if you do not have other
medical insurance or if your other insurance does not cover the loss.
Definitions
COINSURANCE means the percentage of Covered Medical Expenses that the Company
pays.
COPAY/COPAYMENT means a specified dollar amount that the Insured is required to pay
for certain Covered Medical Expenses.
COVERED MEDICAL EXPENSES means reasonable charges which are: 1) not in
excess of Usual and Customary Charges; 2) not in excess of the Preferred Allowance when
the policy includes Preferred Provider benefits and the charges are received from a
Preferred Provider; 3) not in excess of the maximum benefit amount payable per service as
specified in the Schedule of Benefits; 4) made for services and supplies not excluded under
the policy; 5) made for services and supplies which are a Medical Necessity; 6) made for
services included in the Schedule of Benefits; and 7) in excess of the amount stated as a
Deductible, if any.
Covered Medical Expenses will be deemed "incurred" only: 1) when the covered services
are provided; and 2) when a charge is made to the Insured Person for such services.
DEDUCTIBLE means if an amount is stated in the Schedule of Benefits or any
endorsement to this policy as a deductible, it shall mean an amount to be subtracted from
the amount or amounts otherwise payable as Covered Medical Expenses before payment
of any benefit is made. The deductible will apply as specified in the Schedule of Benefits.
DEPENDENT means the spouse (husband or wife) or Domestic Partner of the Named
Insured and their dependent children. Children shall cease to be dependent at the end of
the month in which they attain the age of 19 years and 25 (for full-time student) years.
The attainment of the limiting age will not operate to terminate the coverage of such child
while the child is and continues to be both:
1) Incapable of self-sustaining employment by reason of mental retardation or 2) Chiefly dependent upon the Insured Person for support and maintenance.
Proof of such incapacity and dependency shall be furnished to the Company: 1) by the
Named Insured; and, 2) within 31 days of the child's attainment of the limiting age.
Subsequently, such proof must be given to the Company annually following the child's
attainment of the limiting age.
If a claim is denied under the policy because the child has attained the limiting age for
dependent children, the burden is on the Insured Person to establish that the child is and
continues to be handicapped as defined by subsections (1) and (2).
DOMESTIC PARTNER means a person who is neither married nor related by blood or
marriage to the Named Insured but who is: 1) the Named Insured’s sole spousal equivalent;
2) lives together with the Named Insured in the same residence and intends to do so
indefinitely; and 3) is responsible with the Named Insured for each other’s welfare. A
domestic partner relationship may be demonstrated by any three of the following types of
documentation: 1) a joint mortgage or lease; 2) designation of the domestic partner as
beneficiary for life insurance; 3) designation of the domestic partner as primary beneficiary
in the Named Insured’s will; 4) domestic partnership agreement; 5) powers of attorney for
property and/or health care; and 6) joint ownership of either a motor vehicle, checking
account or credit account
INJURY means bodily injury which is all of the following:
1) directly and independently caused by specific accidental contact with another body 2) unrelated to any pathological, functional, or structural disorder. 3) a source of loss. 4) treated by a Physician within 30 days after the date of accident.
5) sustained while the Insured Person is covered under this policy.
All injuries sustained in one accident, including all related conditions and recurrent
symptoms of these injuries will be considered one injury. Injury does not include loss which
results wholly or in part, directly or indirectly, from disease or other bodily infirmity. Covered
Medical Expenses incurred as a result of an injury that occurred prior to this policy’s
Effective Date will be considered a Sickness under this policy.
INPATIENT means an uninterrupted confinement that follows formal admission to a
Hospital or Skilled Nursing Facility by reason of an Injury or Sickness for which benefits are
payable under this policy.
MEDICAL EMERGENCY means the occurrence of a sudden, serious and unexpected
Sickness or Injury. In the absence of immediate medical attention, a reasonable person
could believe this condition would result in any of the following:
1) Death.
2) Placement of the Insured's health in jeopardy.
3) Serious impairment of bodily functions.
4) Serious dysfunction of any body organ or part.
Expenses incurred for "Medical Emergency" will be paid only for Sickness or Injury which
fulfills the above conditions. These expenses will not be paid for minor Injuries or minor
Sicknesses.
MEDICAL NECESSITY means those services or supplies provided or prescribed by a
Hospital or Physician which are all of the following:
1) Essential for the symptoms and diagnosis or treatment of the Sickness or Injury.
2) Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury.
3) In accordance with the standards of good medical practice.
4) Not primarily for the convenience of the Insured, or the Insured's Physician.
5) The most appropriate supply or level of service which can safely be provided to the The Medical Necessity of being confined as an Inpatient means that both: 1) The Insured requires acute care as a bed patient.
2) The Insured cannot receive safe and adequate care as an outpatient.
This policy only provides payment for services, procedures and supplies which are a Medical
Necessity. No benefits will be paid for expenses which are determined not to be a Medical
Necessity, including any or all days of Inpatient confinement.
PRE-EXISTING CONDITION means: 1) the existence of symptoms which would cause
an ordinarily prudent person to seek diagnosis, care or treatment within the 12 months
immediately prior to the Insured's Effective Date under the policy; or, 2) any condition which
originates, is diagnosed, treated or recommended for treatment within the 12 months
immediately prior to the Insured's Effective Date under the policy.
SICKNESS means sickness or disease of the Insured Person which causes loss, and
originates while the Insured Person is covered under this policy. All related conditions and
recurrent symptoms of the same or a similar condition will be considered one sickness.
Covered Medical Expenses incurred as a result of an Injury that occurred prior to this
policy’s Effective Date will be considered a sickness under this policy.
USUAL AND CUSTOMARY CHARGES means the lesser of the actual charge or a
reasonable charge which is: 1) usual and customary when compared with the charges
made for similar services and supplies; and 2) made to persons having similar medical
conditions in the locality where service is rendered. The Company uses data from FAIR
Health, Inc. to determine Usual and Customary Charges. No payment will be made under
this policy for any expenses incurred which in the judgment of the Company are in excess
of Usual and Customary Charges.
Exclusions and Limitations
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from;or b) treatment, services or supplies for, at, or related to any of the following: 1. Acne; 2. Acupuncture; 3. Allergy; including allergy testing;4. Addiction, such as: nicotine addiction; and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending, shopping, working and religious; codependency; 5. Autistic disease of childhood, hyperkinetic syndromes, milieu therapy, learning disabilities, behavioral problems, intensive behavioral therapies, such as appliedbehavioral analysis; parent-child problems, attention deficit disorder, conceptualhandicap, developmental delay or disorder or mental retardation; 7. Charges and all costs related to or arising from or in connection with all trips to the host country undertaken for the purpose of securing medical treatment or supplies; 12. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy; 13. Custodial Care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, or places mainly for domiciliary or Custodial Care; extended care intreatment or substance abuse facilities for domiciliary or Custodial Care; 14. Dental treatment, as specifically provided in the Schedule of Benefits;15. Elective Surgery or Elective Treatment; 16. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visualdefects and problems; except when due to a covered Injury or disease process; 17. Flat foot conditions; supportive devices for the foot; subluxations of the foot; fallen arches; weak feet; chronic foot strain; symptomatic complaints of the feet; and routinefoot care including the care, cutting and removal of corns, calluses, toenails, andbunions (except capsular or bone surgery); 18. Genetic medicine or genetic testing, including without limitation amniocentesis, genetic screening, risk assessment, prevention and/or to determine pre-disposition,genetic counseling, and/or gene therapy; 19. Health spa or similar facilities; strengthening programs; 20. Hearing examinations; hearing aids; cochlear implants; or other treatment for hearing defects and problems, except as a result of an infection or trauma. "Hearing defects"means any physical defect of the ear which does or can impair normal hearing, apartfrom the disease process; 22. HIV, AIDS Virus, AIDS related Sickness, ARC Syndrome, and AIDS, including any testing for these conditions and any Sickness arising as complications from theseconditions; 23. Hypnosis;24. Immunizations; preventive medicines or vaccines, except where required for treatment 25. Injury caused by, contributed to, or resulting from, the addiction to or use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs or medicines that are not takenin the recommended dosage or for the purpose prescribed by the Insured Person'sPhysician; 26. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 27. Injury or Sickness inside the Insured’s home country; 28. Injury or Sickness outside the United States and its possessions, except when traveling for academic study abroad programs to or from the Insured’s home country; 29. Injury or Sickness when claims payment and/or coverage is prohibited by applicable 30. Injury sustained while (a) participating in any intercollegiate, or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as aparticipant; or (c) while participating in any practice or conditioning program for suchsport, contest or competition; 32. Lipectomy;33. Marital or family counseling;34. Maternity; pregnancy; and Complications of Pregnancy;35. Substance Use Disorders;36. Nuclear, chemical or biological Contamination, whether direct or indirect.
“Contamination” means the contamination or poisoning of people by nuclear and/orchemical and/or biological substances which cause Sickness and/or death; 37. Organ transplants, including organ donation; 38. Orthoptics, visual therapy or visual eye training;39. Outpatient Physiotherapy; except for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2)within the 30 days immediately following the attending Physician's release forrehabilitation; 40. Participation in a riot or civil disorder; commission of or attempt to commit a felony; 42. Prescription Drugs, services or supplies as follows: a) Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use,except as specifically provided in the policy; b) Birth control and/or contraceptives, oral or other, whether medication or device, c) Immunization agents, biological sera, blood or blood products administered on an d) Drugs labeled, “Caution - limited by federal law to investigational use” or e) Products used for cosmetic purposes;f) Drugs used to treat or cure baldness; anabolic steroids used for body building;g) Anorectics - drugs used for the purpose of weight control;h) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, i) Growth hormones; j) Drugs used for tobacco cessation; ork) Refills in excess of the number specified or dispensed after one (1) year of date 43. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for thepurpose or with the intent of inducing conception; premarital examinations;impotence, organic or otherwise; female sterilization procedures; vasectomy; sexualreassignment surgery; reversal of sterilization procedures; 44. Research or examinations relating to research studies, or any treatment for which the patient or the patient’s representative must sign an informed consent documentidentifying the treatment in which the patient is to participate as a research study orclinical research study; 45. Routine Newborn Infant Care, well-baby nursery and related Physician charges;46. Preventive care services; routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; 47. Services provided normally without charge by the Health Service of the institution 48. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; deviated nasal septum, includingsubmucous resection and/or other surgical correction thereof; nasal and sinussurgery, except for treatment of a covered Injury or treatment of chronic purulentsinusitis; 49. Parachuting, hang gliding, glider flying, parasailing, sail planing, or flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of acommercial airline; 51. Speech therapy; naturopathic services; 52. Suicide or attempted suicide while sane or insane (including drug overdose); or 53. Supplies, except as specifically provided in the policy;54. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; 55. Treatment in a Government hospital, unless there is a legal obligation for the Insured 57. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period notcovered); and 58. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat, and treatment of eating disorders such asbulimia and anorexia.
FrontierMEDEX: Global Emergency Services
If you are a participant insured with this insurance plan, you and your insured
spouse/Domestic Partner and minor child(ren) are eligible for FrontierMEDEX. The
requirements to receive these services are as follows:
International Participants, insured spouse/Domestic Partner and insured minor child(ren):
You are eligible to receive FrontierMEDEX services worldwide, except in your home country.
FrontierMEDEX includes Emergency Medical Evacuation and Return of Mortal Remains
that meet the US State Department requirements. The Emergency Medical Evacuation
services are not meant to be used in lieu of or replace local emergency services such as an
ambulance requested through emergency 911 telephone assistance. All services must be
arranged and provided by FrontierMEDEX; any services not arranged by FrontierMEDEX
will not be considered for payment.
Key Services include:
Please visit www.uhcsr.com/frontiermedex for the FrontierMEDEX brochure which
includes service descriptions and program exclusions and limitations.
To access services please call:
(800) 527-0218 Toll-free within the United States
(410) 453-6330 Collect outside the United States
Services are also accessible via e-mail at operations@frontiermedex.com.
When calling the FrontierMEDEX Operations Center, please be prepared to provide: 1. Caller's name, telephone and (if possible) fax number, and relationship to the patient;2. Patient's name, age, sex, and FrontierMEDEX ID Number as listed on your Medical 3. Description of the patient's condition;4. Name, location, and telephone number of hospital, if applicable;5. Name and telephone number of the attending physician; and6. Information of where the physician can be immediately reached.
FrontierMEDEX is not travel or medical insurance but a service provider for emergencymedical assistance services. All medical costs incurred should be submitted to your healthplan and are subject to the policy limits of your health coverage. All assistance services mustbe arranged and provided by FrontierMEDEX. Claims for reimbursement of services notprovided by FrontierMEDEX will not be accepted. Please refer to the FrontierMEDEXinformation in MyAccount at www.uhcsr.com/MyAccount for additional information,including limitations and exclusions.
Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs,
ID Cards, network providers, correspondence and coverage information by logging in to My
Account at www.uhcsr.com/myaccount. Insured participants who don’t already have an
online account may simply select the “create My Account Now” link. Follow the simple,
onscreen directions to establish an online account in minutes using your 7-digit Insurance
ID number or the email address on file.
As part of UnitedHealthcare StudentResources’ environmental commitment to reducing
waste, we’ve introduced a number of initiatives designed to preserve our precious
resources while also protecting the security of a participant’s personal health information.
My Account has been enhanced to include Message Center - a self-service tool that
provides a quick and easy way to view any email notifications we may have sent. In MessageCenter, notifications are securely sent directly to the Insured participant’s email address. Ifthe Insured participant prefers to receive paper copies, he or she may opt-out of electronicdelivery by going into My Email Preferences and making the change there.
One way we are becoming greener is to no longer automatically mail out ID Cards. Instead,
we will send an email notification when the digital ID card is available to be downloaded
from My Account. An Insured participant may also use My Account to request delivery of
a permanent ID card through the mail. ID Cards may also be accessed via our mobile siteat my.uhcsr.com.
Collegiate Assistance Program
Insured Participants have access to nurse advice, health information, and counselingsupport 24 hours a day by dialing the number listed on the permanent ID card. CollegiateAssistance Program is staffed by Registered Nurses and Licensed Clinicians who can helpparticipants determine if they need to seek medical care, need legal/financial advice or mayneed to talk to someone about everyday issues that can be overwhelming.
Claim Procedure
In the event of Injury or Sickness, participants should: 1) Report to their Physician or Hospital.
2) Mail to the address below all medical and hospital bills along with the patient's name and insured participant's name, address, SR ID number, and the name of thepolicyholder, Intrax SP, under which the participant is insured. A Company claimform is not required for filing a claim.
3) File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 90 days of service. Bills submitted after one yearwill not be considered for payment except in the absence of legal capacity.
The Plan is Underwritten by
Student Resources (SPC) Ltd.
A United Health Group Company Submit all Claims or Inquiries to:
UnitedHealthcare StudentResources
P.O. Box 809025
Dallas, Texas 75380-9025
1-866-548-8472
customerservice@uhcsr.com
claims@uhcsr.com
Sales/Marketing Services:
UnitedHealthcare StudentResources
805 Executive Center Drive West, Suite 220
St. Petersburg, FL 33702
1-800-237-0903
E-Mail: info@uhcsr.com
Please keep this Brochure as a general summary of the insurance. The Master Policy isissued to and is on file at Intrax SP. The Master Policy contains all of the provisions,limitations, exclusions and qualifications of your insurance benefits, some of which may notbe included in this Brochure. The Master Policy is the contract and will govern and controlthe payment of benefits.
This Brochure is based on Policy # 2013-202838-1

Source: http://www.studentagency.sk/miranda2/export/sites/sa_sk/sys/galerie-download/StazUSA/UHC_Insurance_Brochure_-_Effective_Jan_1_2014_x2x.pdf