Plan 1

TO STUDENTS AND THEIR PARENTS
The Board of Trustees and the Administration of the Alamo Community College District realize that untimely accidents can seriously affect a student’s academic program. For this reason, the District sponsors a blanket accident plan of benefits that insures all students registered for credit hours. Students may purchase Sickness and Injury benefits for their eligible dependents under a separate plan.

Alamo Community College District (ACCD)

PLANS AVAILABLE THROUGH ACCD ARE:

PLAN I - as outlined in this brochure
PLAN II - Optional student Sickness and Dependent Injury & Sickness Insurance Plan
PLAN III - Compulsory International Student Injury & Sickness Insurance Plan (Dependent Coverage Optional)

PREFERRED PROVIDER NETWORK

To maximize your savings and reduce your out-of-pocket expenses, select a Preferred Provider from the First Health preferred provider network. It is to your advantage to utilize a Preferred Provider because significant savings can be achieved from the substantially lower rates these providers have agreed to accept as payment for their services. Preferred Providers are independent contractors and are neither employees nor agents of Alamo Community College District, Bollinger, Inc., or Monumental Life Insurance Company. A complete listing of participating providers is available on the Internet at:

ELIGIBILITY

Students are eligible if they are registered for credit hours. NOTE: All retired military personnel enrolled in this plan will be covered except for Injuries incurred as a result of said Insured’s participation in military activities such as, but not limited to, training and war. Active military and dual credit (high school/community college) students are not covered.

EFFECTIVE AND TERMINATION DATES

Students covered by this Plan will be provided with twenty-four hour coverage, 7 days a week.

The Policy will become effective at 12:01 a.m. on August 27, 2007. The Insured student’s individual coverage becomes effective on the effective date of the Coverage Period for which he/she is enrolled and premium is paid.

The Policy will terminate at 12:01 a.m. on August 25, 2008. The Insured student’s coverage will terminate on that date, or at the end of the period for which premium was paid, whichever is earlier.

COVERAGE PERIODS:

Fall 08/27/07 through 01/13/08
Spring 01/14/08 through 06/01/08
Summer 06/02/08 through 07/10/08
Summer II 07/11/08 through 08/25/08

DEFINITIONS

ELECTIVE SURGERY OR ELECTIVE TREATMENT means any surgery or treatment that is not Medically Necessary, including any service, treatment, or supplies that are deemed by us to be research or experimental; or are not recognized as generally accepted medical practices in the United States. Elective Surgery and Elective Treatment do not include any procedures deemed a Medical Necessity. Elective surgery does not mean a cosmetic procedure required to correct an Injury for which benefits are otherwise payable under the Policy.

INJURY means bodily injury caused by an accident. The accident must occur while the Insured person's insurance is in force under the Policy. All injuries sustained by one person in any one accident, including all related conditions and recurrent symptoms of these Injuries, are considered a single covered Injury. The Injury must be the direct cause of loss and must be independent of all other causes.

MEDICAL EMERGENCY means the occurrence of a sudden, serious and unexpected Injury. In the absence of immediate medical attention, a reasonable person could believe this condition would result in death, permanent placement of the Insured person's health in jeopardy, serious impairment of bodily functions or serious and permanent dysfunction of any body organ or part. Expenses incurred for a medical emergency will be paid only for Injury which fulfills the above conditions. These expenses will not be paid for minor injuries.

MEDICALLY NECESSARY means care which a Physician has determined to be certifiably essential for the diagnosis or treatment of an Injury. This determination must be based on objective results produced by an examination of the Insured person's demonstrable symptoms. The Physician's treatment plan may be reviewed by an impartial third party whose determination will be binding on Bollinger, Inc. and the Insured.

USUAL AND CUSTOMARY CHARGE means those charges for necessary treatment and services that are reasonable for the treatment of cases of comparable severity and nature. This will be derived from the mean charge based on the experience in a related area of the service delivered.

I. BASIC PLAN

ACCIDENT MEDICAL EXPENSE BENEFIT
Deductible: $10 for each Covered Injury
If Injury is sustained while coverage is in force and requires treatment within 30 days, this Plan will pay the Usual & Customary Charge or the amount listed below, if less, for Covered Medical Expenses actually incurred within 52 weeks following the date of the Injury, not to exceed an aggregate limit of $5,000 for any one Injury.

Covered Medical Expenses include:

  1. Medical and surgical treatment by a Doctor (excluding manipulation and massage);
  2. Hospital Confinement;
  3. Miscellaneous hospital expenses necessary for treatment such as: x-ray examinations, laboratory tests, anesthesia supplies, drugs or medicines, surgical supplies, operating room, plaster casts, therapeutic services, pre-admission testing and temporary surgical appliances if the insured is confined as a bed patient in a hospital.
  4. Dental treatment made necessary by Injury to sound, natural teeth. Maximum $250 per tooth.
  5. Ambulance expense.
  6. Outpatient lab and x-ray.
  7. Prescription drugs when prescribed by the attending Doctor. Maximum $100 for each Injury.
  8. Any and all preventive treatment (i.e., testing for Hepatitis A, Hepatitis B, Hepatitis C, HIV, etc.), not otherwise covered under the Policy that may be required as a result of accidental “needlestick” Injury or bodily fluid contact exposure is covered up to a maximum of $1,200 for school sponsored Allied Health Nursing Programs and Ancillary Medicine.

II. MAJOR MEDICAL COVERAGE SUPPLEMENT

When $5,000 of Covered Medical Expenses has been paid under the Basic Plan for an Injury, this Major Medical Coverage Supplement will pay 80% of the Usual & Customary Charges for the covered medical expenses incurred within the 52 week period (as listed under the Basic Plan) not to exceed a maximum benefit of $25,000 for all benefits paid under the Basic Plan and this Major Medical Coverage Supplement for any one Injury. Hospital room and board benefits are limited to the semi-private rate.

III. ACCIDENTAL DEATH AND
DISMEMBERMENT BENEFIT

Upon receipt of due proof that an Insured person suffers a loss shown below, we will pay the benefit shown below. The benefit payable is subject to the following conditions:

  1. the loss must occur as a direct result of an Injury; and
  2. the loss must occur within 180 days of the accident causing the Injury.

Loss: Benefit:
Life .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5,000
Both Hands; Both Feet or Sight of Both Eyes. . . . $5,000
One Hand and One Foot . . . . . . . . . . . . . . . . . . $5,000
One Hand and Sight of One Eye . . . . . . . . . . . . . $5,000
One Foot and Sight of One Eye . . . . . . . . . . . . . $5,000
One Hand; One Foot or Sight of One Eye .  . . . . . $2,500
Thumb and Index Finger of Same Hand . . . . . . . $1,250

MANDATED BENEFITS: This plan also covers all Mandated Benefits as required by the State of Texas. For complete details, please review the Master Policy on file at the School.

NON-DUPLICATION OF BENEFITS

If the Insured person is covered by other valid and collectible insurance, all benefits payable by such insurance in excess of $5,000 will be determined before benefits will be paid by the Policy. The Policy is the second payor to any other insurance having primary
status or no coordination or non-duplication of benefits provision.

Benefits paid by the Policy will not exceed: (1) any applicable Policy maximums; and (2) 100% of the compensable expenses incurred when combined with benefits paid by any other valid and collectible insurance.

PRE-EXISTING CONDITION: No benefits will be payable for the Insured's Pre-existing Conditions.  They are defined as an Injury sustained for which an Insured person noticed symptoms or was medically diagnosed, treated (including medication) or advised by a Physician within the six months immediately prior to his effective date of coverage under the Policy.

Covered medical expenses resulting from a Pre-existing Condition will not be covered unless:

  1. six consecutive months have elapsed during which no medical treatment or advice is given by a physician for such condition; or
  2. the Insured person has been insured under
    the Policy or the College's prior policies for the immediately prior year; or
  3. the Insured person has been receiving benefits under the College's prior policies and has been continuously insured since the date of Injury.
     

REFUND OF PREMIUM

Premiums received by the Company will be considered fully earned and nonrefundable. Refund of premium will be considered only if it is determined that the Insured Person did not meet the eligibility requirements at the time of enrollment.

EXCLUSIONS

Benefits will not be paid under the Policy for any expenses which result from:

  1. Expenses incurred as the result of dental treatment, except as specifically provided for treatment resulting from Injury to natural teeth;
  2. Services that are provided normally without charge by the College's health center, infirmary or hospital, or by any person employed by the College;
  3. Eyeglasses, radial keratotomy, contact lenses, hearing aids or prescriptions or examinations except as required for repair caused by a covered Injury;
  4. Suicide, attempted suicide or intentionally self-inflicted Injury while sane or insane;
  5. Declared or undeclared war, riot, civil disorder, civil commotion or acts of terrorism;
  6. Riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as fare-paying passenger in an aircraft operated by a commercial scheduled airline. This exclusion does not apply to Insured students while taking flight instructions for College credit;
  7. Injury for which benefits are payable under any Worker's Compensation or Occupational Disease Law;
  8. Injury sustained while in the service of the armed forces of any country. When an Insured enters the armed forces, we will refund any unearned pro-rata premium with respect to such person;
  9. Treatment provided in a government hospital unless there is a legal obligation to pay such charges in the absence of other insurance;
  10. Elective Surgery or Elective Treatment;
  11. Injury resulting from racing or speed contests, skin diving or sky diving, mountaineering (where ropes or guides are customarily used), or any other hazardous sport or hobby;
  12. Expenses for preventative medicines, prescription drugs or vaccines or injections administered during an outpatient visit, except an injection given by a Physician in private practice who will certify that a Medical Emergency was required for the condition;
  13. Services and supplies not Medically Necessary for the diagnosis recommended by the attending Physician;
  14. Taking of any drug, medication, narcotic or hallucinogen, unless as prescribed by a Physician;
  15. Homemaking, companion or chronic (custodial) care services. Charges of a home health aide who is a member of your household. Charges of any care provided by relatives (by blood, marriage or adoption);
  16. Expenses resulting from a motor vehicle accident for which benefits are payable from other valid insurance;
  17. Committing or attempting to commit an assault or felony; or fighting, except in self defense;
  18. Elective abortion;
  19. Routine physical examinations, preventive testing or treatment, screening exams or testing in the absence of Injury, pre marital examinations, pre-employment examinations, health examinations or pre-school physical examinations.
  20. Injury resulting from the playing, practice, or conditioning in any intercollegiate, or interscholastic, sport, contest or competition sponsored by the College, any professional or semi-professional sport, or Injury sustained while traveling to or from such sport, contest or competition as a participant;
  21. Injury sustained as a result of the use of alcohol or the misuse of drugs, medicines, or narcotics, unless taken in the dosage and for the purpose prescribed by the Insured person’s physician;
  22. Expenses resulting from a motor vehicle accident if the Insured is not properly licensed to operate the motor vehicle within the jurisdiction in which the accident takes place (this exclusion will not apply to passengers if they are Insured under the Policy;
  23. Blood or blood plasma that is replaced by or for the Insured person; and
  24. Cosmetic surgery or other reconstructive procedures or services except as the result of Injury occurring while coverage is in effect as to the Insured person.

Please keep this Brochure as a general summary of your coverage. The Master Policy on file at the College contains all of the provisions, exclusions and qualifications of your insurance benefits, some of which may not be included in this Brochure. If any discrepancy exists between this Brochure and the Master Policy, the Master Policy will govern and control the payment of benefits.

HOW TO FILE A CLAIM

  1. Obtain a Claim form. Claim forms may be obtained from the College Nurse or online.

    It is your responsibility to obtain and complete the Insurance Claim Form. You need to file one claim form per Accident each school year.
     
  2. Attach all itemized medical bills and send with completed claim form to Bollinger, Inc., P.O. Box 727, Short Hills, NJ 07078-0727, 866-267-0092 (Claims/Coverage), 800-526-1379 (Other Questions)
     
  3. Written notification of claim must be given within 90 days after the occurrence or commencement of any loss covered by the Policy. Bills for which benefits are paid must be submitted within 90 days of the date of treatment. NOTE: If these claim procedures are not followed, your claim may be delayed due to lack of information.

ADMINISTERED BY:

P.O. Box 727
Short Hills, NJ 07078-0727
866-267-0092 (Claims/Coverage)
800-526-1379 (Other Questions)

LOCAL SERVICING BROKER:
Academic Health Plans Inc.
P.O. Box 1605
Colleyville, TX 76034-1605
888-308-7320

PLAN UNDERWRITTEN BY:
MONUMENTAL LIFE
INSURANCE COMPANY
Cedar Rapids, Iowa

PREFERRED PROVIDER NETWORK:

Policy Form: SH1000GPM(Rev.2004).TX  
Policy No. CTX124D

2344439