2011-1606-77 brochure-v4_layout

2011-2012STUDENTINJURY AND SICKNESSINSURANCE PLAN Limited Benefit Plan. Please Read CarefullyDesigned Especially for the Students at NEBRASKA
METHODIST
Table of Contents
Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Accidental Death and Dismemberment Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Benefits for Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . .12Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back CoverOnline Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back Cover Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality ofyour non-public personal information. We do not disclose any non-public personalinformation about our customers or former customers to anyone, except as permitted orrequired by law. We believe we maintain appropriate physical, electronic and proceduralsafeguards to ensure the security of your non-public personal information. You may obtaina copy of our privacy practices by calling us toll-free at 1-800-767-0700 or visiting us atwww.uhcsr.com.
Eligibility
All registered students taking 3 or more credit hours are automatically enrolled in thisinsurance Plan at registration, unless proof of comparable coverage is furnished.
Students must actively attend classes for at least the first 31 days after the date for whichcoverage is purchased. Home study, correspondence, Internet, and television (TV) coursesdo not fulfill the Eligibility requirements that the student actively attend classes. TheCompany maintains its right to investigate student status and attendance records to verifythat the policy Eligibility requirements have been met. If the Company discovers theEligibility requirements have not been met, its only obligation is to refund premium.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents arethe spouse and unmarried children under 19 years of age or 23 years if a full-time studentat an accredited institution of higher learning who are not self-supporting. DependentEligibility expires concurrently with that of the Insured student.
Effective and Termination Dates
The Master Policy on file at the school becomes effective at 12:01 a.m., August 23, 2011.
The individual student’s coverage becomes effective on the first day of the period for whichpremium is paid or the date the enrollment form and full premium are received by theCompany (or its authorized representative), whichever is later. The Master Policy terminatesat 11:59 p.m., August 22, 2012. Coverage terminates on that date or at the end of theperiod through which premium is paid, whichever is earlier. Dependent coverage will not beeffective prior to that of the Insured student or extend beyond that of the Insured student.
Refunds of premiums are allowed only upon entry into the armed forces.
The Policy is a Non-Renewable One Year 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 of Benefits" provision has been exhausted, all benefits cease to exist,and under no circumstances will further payments be made.
Pre-Admission Notification
UMR Care Management 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 fiveworking days prior 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 to MedicalEmergency.
UMR Care Management 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 thatbenefits will be paid.
Schedule of Medical Expense Benefits
Up To $75,000 Maximum Benefit Paid as Specified Below (For Each Injury or Sickness) Preferred Provider Deductible: $150 (Per Insured Person, Per Policy Year) Out of Network Deductible: $250 (Per Insured Person, Per Policy Year) The Policy provides benefits for the Usual & Customary Charges incurred by an InsuredPerson for loss due to a covered Injury or Sickness up to the Maximum Benefit of $75,000for each Injury or Sickness. The Preferred Provider for this plan is UnitedHealthcare Options PPO. If care is received from a Preferred Provider any Covered Medical Expenses will be paidat the Preferred Provider level of benefits. If the Covered Medical Expense is incurred dueto a Medical Emergency, benefits will be paid at the Preferred Provider level of benefits. Inall other situations, reduced or lower benefits will be provided when an Out-of-Networkprovider is used. All benefit maximums are combined Preferred Provider and Out-of-Network unless notedbelow. Benefits will be paid up to the Maximum Benefit for each service as scheduledbelow. Covered Medical Expenses include: PA = Preferred Allowance U&C = Usual & Customary Charges
INPATIENT
Preferred Providers Out-of-Network
Hospital Expense, daily semi-private room 80% of PA
rate; and general nursing care provided by the Hospital. Hospital Miscellaneous Expenses, anesthesia, drugs (excluding take home drugs)or medicines, therapeutic services, andsupplies. In computing the number of dayspayable under this benefit, the date ofadmission will be counted, but not the date ofdischarge. Intensive Care
Routine Newborn Care, 4 days Hospital
Confinement expense maximum. WhileHospital Confined; and routine nursery careprovided immediately after birth. Physiotherapy
Surgeon’s Fees, in accordance with data 80% of PA /
provided by FAIR Health, Inc. If two or more $5,000 maximum procedures are performed through the same For Each Injury or incision or in immediate succession at the Sickness same operative session, the maximum amount paid will not exceed 50% of the secondprocedure and 50% of all subsequentprocedures.
INPATIENT
Preferred Providers Out-of-Network
Assistant Surgeon
Anesthetist,
Registered Nurse’s Services, private duty 80% of PA
Physician’s Visits, benefits do not apply when 80% of PA
related to surgery. Benefits are limited to onevisit per day.
Pre-Admission Testing, payable within 3 80% of PA
Psychotherapy, benefits are limited to one
visit per day. Psychiatric Hospitals are notcovered.
OUTPATIENT
Surgeon’s Fees, in accordance with data 80% of PA /
provided by FAIR Health, Inc. If two or more $5,000 maximum procedures are performed through the same For Each Injury or incision or in immediate succession at the Sickness same operative session, the maximum amount paid will not exceed 50% of the secondprocedure and 50% of all subsequentprocedures.
Day Surgery Miscellaneous, related to 80% of PA
scheduled surgery performed in a Hospital, including the cost of the operating room; including professional fees; anesthesia; drugs or medicines; and supplies. Usual andCustomary Charges for Day SurgeryMiscellaneous are based on the OutpatientSurgical Facility Charge Index.
Assistant Surgeon
Anesthetist,
administered in connection with outpatientsurgery.
Physician’s Visits, benefits for Physician’s 80% of PA
Visits do not apply when related to surgery orPhysiotherapy. Benefits are limited to one visitper day.
Physiotherapy, benefits are limited to one visit 80% of PA
per day. Review of Medical Necessity will be performed after 12 visits per Injury or Sickness. OUTPATIENT
Preferred Providers Out-of-Network
Medical Emergency Expenses, $350 80% of PA
maximum for each Injury or Sickness if notadmitted, use of the emergency room andsupplies. Treatment must be rendered within72 hours from time of Injury or first onset ofSickness.
Diagnostic X-ray & Laboratory Services,
$800 maximum for each Injury of Sickness.
Injections
Tests & Procedures, diagnostic services and 80% of PA
medical procedures performed by a Physician,other than Physician’s Visits, Physiotherapy,x-rays and lab procedures.
Chemotherapy & Radiation Therapy
Prescription Drugs, $15 Deductible per 80% of U&C
Prescription up to a 31-day supply perprescription / $700 maximum Per Policy Year Psychotherapy, $75 maximum per day / 10
visits maximum Per Policy Year. Benefits arelimited to one visit per day. Including all relatedor ancillary charges incurred as a result ofMental & Nervous Disorder.
Ambulance Services, $500 maximum for 80% of PA
Durable Medical Equipment,
maximum for each Injury or Sickness, a writtenprescription must accompany the claim whensubmitted. Replacement equipment is notcovered.
Consultant Physician Fees, when requested 80% of PA
and approved by the attending Physician.
Dental Treatment, made necessary by Injury 80% of U&C
Maternity & Complications of Pregnancy
Alcoholism/Drug Abuse, $500 maximum 80% of PA
Elective Abortion
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 school area are: UnitedHealthcare Options PPO.
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 1-800-767-0700, by visiting the web at www.uhcsr.com, and/or by
asking the provider when making an appointment for services.
"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. Insured’s
may incur significant out-of-pocket expenses with these providers. Charges in excess of
the insurance payment are the Insured’s responsibility.
Regardless of the provider, each Insured is responsible for the payment of their Deductible.
The Deductible must be satisfied before benefits are paid. The Company will pay according
to the benefit limits in the Schedule of Benefits.
Inpatient Hospital Expenses
PREFERRED HOSPITALS - Eligible inpatient Hospital expenses at a Preferred Hospital
will be paid at 80%, up to any limits specified in the Schedule of Benefits.
Call 1-800 767-0700 for information about Preferred Hospitals.
OUT-OF-NETWORK HOSPITALS - If care is provided at a Hospital that is not a Preferred
Provider, eligible inpatient Hospital 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 80% of Preferred Allowance or up to any specified in the Schedule of Benefits. Allother providers will be paid according to the benefit limits in the Schedule of Benefits.
Maternity Testing
This policy does not cover routine, preventive or screening examinations or testing unless
Medical Necessity is established based on medical records. The following maternity routine
tests and screening exams will be considered if all other policy provisions have been met:
Initial screening at first visit – Pregnancy test: Urine human chorionic gonatropin (HCG),
Asymptomatic bacteriuria: Urine culture, Blood type and Rh antibody, Rubella, Pregnancy-
associated plasma protein-A (PAPPA) (first trimester only), Free beta human chorionic
gonadotrophin (hCG) (first trimester only), Hepatitis B: HBsAg, Pap smear, Gonorrhea: Gc
culture, Chlamydia: chlamydia culture, Syphilis: RPR, HIV: HIV-ab; and Coombs test; Each
visit – Urine analysis; Once every trimester – Hematocrit and Hemoglobin; Once during
first trimester – Ultrasound; Once during second trimester – Ultrasound (anatomy
scan); Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen test Alpha-fetoprotein
(AFP), Estriol, hCG, inhibin-a; Once during second trimester if age 35 or over -
Amniocentesis or Chorionic villus sampling (CVS); Once during second or third
trimester – 50g Glucola (blood glucose 1 hour postprandial); and Once during third
trimester - Group B Strep Culture. Pre-natal vitamins are not covered. For additional
information regarding Maternity Testing, please call the Company at 1-800-767-0700.
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. Payment under
this benefit will not exceed the policy Maximum Benefit.
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
No benefits are payable for any expense incurred for Injury or Sickness which has been paidor is payable by other valid and collectible insurance or under an automobile insurancepolicy.
However, this Excess Provision will not be applied to the first $100 of medical expensesincurred.
Covered Medical Expenses excludes amounts not covered by the primary carrier due topenalties imposed as a result of the Insured’s failure to comply with policy provisions orrequirements.
Important: Excess Provision has no practical application if you do not have other medicalinsurance or if your insurance does not cover the loss.
Mandated Benefits
Benefits for Mammography
Benefits will be paid the same as any other Sickness for a screening mammography asfollows: 1) For women who are thirty-five years of age and older but younger than forty years of age, one base-line mammogram between thirty-five and forty years of age; 2) For women who are forty years of age and older but younger than fifty years of age, one mammogram every two years or more frequently based on the patient’sPhysician’s recommendation; and 3) For women who are fifty years of age or older, one mammogram every year.
Benefits shall be subject to all Deductibles, coinsurance, limitations and any other provisionsof the policy.
Benefits for Diabetes
Benefits will be paid the same as any other Sickness for equipment, supplies, medication,and outpatient self-management training, including medical nutrition therapy, for thetreatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, andnon-insulin-using diabetes if prescribed by a Physician.
Benefits shall include the following equipment, supplies, medication, and patient self-management training for the use of the equipment such as: blood glucose monitors, bloodglucose monitors for the legally blind, test strips for glucose monitors, urine testing strips,insulin, injection aids, lancet and lancet devices, syringes, insulin pumps and all supplies forthe pump, insulin infusion devices, oral agents for controlling blood sugars, glucose agentsand glucagon kits, insulin measurement and administration aids for the visually impaired,patient management material that provide essential diabetes self-management information,and podiatric appliances for the prevention of complications associated with diabetes.
Benefits shall cover home visits when Medically Necessary and prescribed by a Physician.
Diabetes self-management training, including medical nutrition therapy, shall be provided byan American Diabetes Association Recognized Diabetes Self-Management EducationProgram or a Physician.
Physician prescribed diabetes self-management training shall be covered at diagnosis,when symptoms or conditions change, and when new medications or treatments areprescribed. Diabetes self-management education must be deemed to be MedicallyNecessary by a Physician to be eligible for coverage and such coverage shall not exceedfive hundred dollars ($500.00) in a two-year period.
“Patient self-management” means educational and training services furnished to anindividual with diabetes in an outpatient setting by an individual or entity with experience indiabetes, in consultation with the Physician who is managing the patient’s condition, whichPhysician certifies that such services are needed under a comprehensive plan of carerelated to the individual’s condition to ensure therapy or compliance or to provide theindividual with necessary skills and knowledge, including skills related to the self-administration of injectable drugs which participate in the management of the individual’scondition.
Benefits shall be subject to all Deductibles, coinsurance, limitations and any other provisionsof the policy.
Definitions
Injury means bodily injury which is: 1) directly and independently caused by specific
accidental contact with another body or object; 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; and 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.
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 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 of the Policyholder. 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: 1. Acne; acupuncture; allergy, including allergy testing; 2. Addiction, such as: nicotine addiction and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending, shopping, working and religious; codependency; 3. Assistant Surgeon Fees;4. Behavioral problems, parent-child problems;5. Biofeedback;6. Injections; 8. Congenital conditions, except as specifically provided for Newborn or adopted Infants;9. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adopted children;removal of warts, non-malignant moles and lesions; 10. Custodial care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or custodial care;extended care in treatment or substance abuse facilities for domiciliary or custodialcare; 11. Dental treatment, except for accidental Injury to Sound, Natural Teeth; 12. Elective Surgery or Elective Treatment; 13. Elective abortion;14. 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 disease process; 15. Foot care including: flat foot conditions, supportive devices for the foot, subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toenails,fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet; 16. Health spa or similar facilities; strengthening programs; 17. 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 canimpair normal hearing, apart from the disease process; 20. Immunizations, preventive medicines or vaccines, except where required for treatment 21. 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; 22. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 23. Injury sustained while (a) participating in any club, 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; 24. Investigational services;25. Lipectomy;26. Organ transplants, including organ donation; 27. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or 28. Pre-existing Conditions, except for individuals who have been continuously insured under the school's student insurance policy for at least 12 consecutive months; ThePre-existing Condition exclusionary period will be reduced by the total number ofmonths that the Insured provides documentation of continuous coverage under a priorhealth insurance policy which provided benefits similar to this policy; 29. 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 asspecifically provided in the Benefits for Diabetes; b) Immunization agents, biological sera, blood or blood products administered on an c) Drugs labeled, “Caution-limited by federal law to investigational use” or experimental drugs except for drugs on the basis that the drug or combination ofdrugs has not been approved by the federal Food and Drug Administration for thetreatment of another specific type of cancer if (a) the drug or combination of drugsis recognized for treatment of the other specific type of cancer in the United StatesPharmacopeia-Drug Information and the drug or combination of drugs is approvedfor sale by the federal Food and Drug Administration or (b) the drug or combinationof drugs is recognized for treatment of the other specific type of cancer in medicalliterature and the drug or combination of drugs is approved for sale by the federalFood and Drug Administration; or any drug or combination of drugs on the basisthat the drug or combination of drugs has not been approved by the federal Foodand Drug Administration for the treatment of human immunodeficiency virus oracquired immunodeficiency syndrome if (a) the drug or combination of drugs isrecognized for treatment of human immunodeficiency virus or acquiredimmunodeficiency syndrome in the United States Pharmacopeia-Drug Informationand the drug or combination of drugs is approved for sale by the federal Food andDrug Administration or (b) the drug or combination of drugs is recognized fortreatment of human immunodeficiency virus or acquired immunodeficiencysyndrome in medical literature and the drug or combination of drugs is approved forsale by the federal Food and Drug Administration; d) Products used for cosmetic purposes;e) Drugs used to treat or cure baldness; anabolic steroids used for body building;f) Anorectics - drugs used for the purpose of weight control;g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, h) Growth hormones; ori) Refills in excess of the number specified or dispensed after one (1) year of date of 30. 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; tubal ligation; vasectomy; sexual reassignment surgery; reversalof sterilization procedures; 31. 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; 32. Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery; 33. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specificallyprovided in the policy; 34. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 35. 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 chronic purulent sinusitis; 36. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; 38. Speech therapy; naturopathic services;39. Suicide or attempted suicide while sane or insane (including drug overdose); or 40. Supplies, except as specifically provided in the policy; 41. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic 42. Treatment in a Government hospital, unless there is a legal obligation for the Insured 43. 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 44. 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. Exception: benefits will be provided for the treatment ofdehydration and electrolyte imbalance associated with eating disorders.
Collegiate Assistance Program
Insured Students have access to nurse advice, health information, and counseling support24 hours a day, 7 days a week by dialing the access number indicated on the permanentID Card. Collegiate Assistance Program is staffed by Registered Nurses and LicensedClinicians who can help students determine if they need to seek medical care, needlegal/financial advice or may need to talk to someone about everyday issues that can beoverwhelming.
Scholastic Emergency Services:
Global Emergency Medical Assistance
If you are a student insured with this insurance plan, you and your insured spouse and minorchild(ren) are eligible for Scholastic Emergency Services (SES). The requirements toreceive these services are as follows: Domestic Students, insured spouse and insured minor child(ren): You are eligible for SES
when 100 miles or more away from your campus address and 100 miles or more away from
your permanent home address or while participating in a Study Abroad program.
SES 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 SES services must be
arranged and provided by SES, Inc.; any services not arranged by SES, Inc. will not be
considered for payment.
Key Services include:
* Medical Consultation, Evaluation and Referrals * Prescription Assistance* Foreign Hospital Admission Guarantee * Lost Luggage or Document Assistance* Care for Minor Children Left Unattended Due to a Medical Incident Please visit your school's insurance coverage page at www.uhcsr.com for the SES Global
Emergency Assistance Services brochure which includes service descriptions and program
exclusions and limitations.
To access services please call:
(877) 488-9833 Toll-free within the United States
(609) 452-8570 Collect outside the United States
Services are also accessible via e-mail at [email protected].
When calling the SES 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 Reference Number;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 SES is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan andare subject to the policy limits of your health coverage. All assistance services must bearranged and provided by SES, Inc. Claims for reimbursement of services not provided bySES will not be accepted. Please refer to your SES brochure or Program Guide atwww.uhcsr.com for additional information, including limitations and exclusions pertaining tothe SES program.
Claim Procedure
In the event of Injury or Sickness, students should: 1) Report to the Student Health Service or Infirmary for treatment or referral, or when not in school, to their Physician or Hospital.
2) Mail to the address below all medical and hospital bills along with the patient's name and insured student's name, address, Social Security number and name of theCollege under which the student is insured. A Company claim form is not requiredfor 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:
Submit all Claims or Inquiries to:
UnitedHealthcare StudentResources
E-mail Customer Service Questions: [email protected] Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs,correspondence and coverage information via My Account at www.uhcsr.com. Insureds canalso print a temporary ID card, request a replacement ID card and locate network providersfrom My Account. If you don’t already have an online account, simply select the “Create an Account” link fromthe home page at www.uhcsr.com. Follow the simple, onscreen directions to establish anonline account in minutes. Note that you will need your 7-digit insurance ID number tocreate an online account. If you already have an online account, just log in fromwww.uhcsr.com to access your account information.
PLEASE KEEP THIS BROCHURE AS A GENERAL SUMMARY OF THE
INSURANCE. The Master Policy on file at the College contains all of the provisions,
limitations, exclusions and qualifications of your insurance benefits, some of which may not
be included in this Brochure. The Master Policy is the contract and will govern and control
the payment of benefits.
This Brochure is based on Policy #2011-1606-77

Source: http://www.methodistcollege.edu/Documents/Student%20Health%20Services/2011-1606-77Brochure-v4.pdf