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Microsoft word - plan summary - gto 2013-2014 (wilbraham and monson academy.docx

Eligibility Statement: All International students
registered for credit courses are automatically enrolled in this insurance Plan at registration, unless proof of Effective and Termination Dates: This Insurance
Plan becomes effective at 12:01 am on August 15,
2013. Coverage becomes effective on the first day of
the period for which premium is paid or the date the enrollment form and full premium are received by the Your student’s school is pleased to offer a Primary Company (or its authorized representative), whichever Injury and Sickness Insurance Plan. This Plan is is later. This Insurance Plan terminates at 11:59 pm underwritten by Student Resources (SPC) Ltd. on August 14, 2014. Coverage terminates on that
(A UnitedHealth Group Company) and is based on date or at the end of the period through which premium is paid, whichever is earlier. Refunds of premiums are allowed only upon entry into the armed Please read the certificate of coverage (the brochure). The brochure provides more detail of the coverage including benefits, exclusions, any reductions or limitations and the terms under which the coverage may be continued in force. Copies of this brochure may be obtained by contacting the health center at the Schedule of Medical Expense Benefits – Injury and Sickness
Up to $500,000 Maximum Benefit (For each Injury or Sickness) The Policy provides benefits for Usual and Customary charges incurred by an Insured Person for loss due to a covered Injury and Sickness up to the Maximum Benefit of $500,000 for each Injury or Sickness. Usual & Customary Charges (U&C) are based on data provided by Fair Health, Inc. using the 90th percentile based on • No network – permit any qualified provider • Urgent Care and Outpatient Facility or Clinic • No co-pays, deductibles or co-insurance • Pre-existing conditions are covered from day • In and out-patient mental illness treatment (including RX) treated as any other illness • Hospital room and board paid – including • Out-patient physiotherapy covered at 100% of intensive care, nursing care, operating room, lab tests, x-ray exams, anesthesia, drugs or • Acne treatment covered under prescription medicines, therapeutic services and supplies • Surgery paid at 100% of U&C charges • Allergy treatment (not testing) covered under • Interscholastic sports related injuries covered • Lab tests and X-rays covered under out-patient • Prescription drugs covered at 100% up to • Treatment of injury to sound natural teeth • Dr.’s visits covered at 100% of U&C charges • Braces and appliances paid at 100% of U&C • Medical Emergency Expenses covered at • Repatriation and medical evacuation benefits • Diabetes Services in connection with the treatment of diabetes for Medically Necessary • Your Child is covered anytime/anywhere in the outpatient self-management and RX drugs and world, with the exception of his/her home Frontier MEDEX Global Emergency Medical Assistance: If you are a student insured with this insurance
plan, you are eligible for Frontier MEDEX Emergency Services. International students are eligible to
receive Frontier MEDEX Emergency Services worldwide, except in their home country. Please see the
brochure for a more detailed description of services and service process.
Policy 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, Immunization agents, except as specifically provided in Addiction, except as specifically provided in the policy; the policy, biological sera, blood or blood products administered on an outpatient basis; Drugs labeled, “Caution - limited by federal law to investigational use” Congenital conditions, except as specifically provided or experimental drugs; Products used for cosmetic purposes; Drugs used to treat or cure baldness; anabolic steroids used for body building; Anorectics - Cosmetic procedures, except as specifically provided for in the policy drugs used for the purpose of weight control; Fertility agents or sexual enhancement drugs, such as Parlodel, Dental treatment, except for accidental Injury to Sound, Natural Teeth; Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; Growth hormones; or Refills in excess of the number specified or dispensed after one (1) year of date Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact Reproductive/Infertility services including but not limited lenses, vision correction surgery, or other treatment for to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for visual defects and problems; except when due to a covered Injury or disease process; the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or Routine foot care including the care, cutting and otherwise; female sterilization procedures; vasectomy; removal of corns, calluses, and bunions (except sexual reassignment surgery; reversal of sterilization Hearing examinations; hearing aids; or cochlear implants; or other treatment for hearing defects and Routine Newborn Infant Care, well-baby nursery and related Physician charges; in excess of 48 hours for problems, except as a result of an infection or trauma. vaginal delivery or 96 hours for cesarean delivery; “Hearing defects” means any physical defect of the ear which does or can impair normal hearing, apart from the Preventive care services; routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specifically provided in the policy; Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where Services provided normally without charge by the Health Service of the institution attended by the Insured; or required for treatment of a covered Injury, or as services covered or provided by a student health fee; Skeletal irregularities of one or both jaws, including Injury caused by, contributed to, or resulting from the orthognathia and mandibular retrognathia; addiction to or use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs or medicines that are not taken in the recommended dosage or for Skydiving, parachuting, hang gliding, glider flying, the purpose prescribed by the Insured Person’s parasailing sail planing, bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; Injury or Sickness for which benefits are paid or payable under any Worker’s Compensation or Occupational Disease Law or Act, or similar legislation Supplies, except as specifically provided in the policy; Injury or Sickness inside the Insured’s home country; Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; Injury or Sickness when claims payment and/or coverage is prohibited by applicable law; except as specifically provided in the policy; Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting; War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium Prescription Drugs, services or supplies as follows; will be refunded upon request for such period not Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of use, except as specifically provided in the policy; THIS IS ONLY A PARTIAL OUTLINE OF BENEFITS AND EXCLUSIONS AS UNDERWRITTEN
BY STUDENT RESOURCES (SPC), LTD. (A UNITED HEALTHGROUP COMPANY) AND SERVICED BY CLIFFORD ALLEN ASSOCIATES, LTD.
CERTIFICATES WILL BE ISSUED CONTAINING AN IN-DEPTH EXPLANATION

Source: http://www.wma.us/uploaded/Parents/Plan_Summary_-_GTO_2013-2014_(Wilbraham_and_Monson_Academy.pdf

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