PLAN 2

CLICK HERE TO PURCHASE YOUR INSURANCE ONLINE
(ONLY AVAILABLE FOR PLAN II) TO STUDENTS AND THEIR PARENTS

TO STUDENTS AND THEIR PARENTS

The Board of Trustees and the Administration of the Alamo Community College District realize that untimely accidents or a severe illness can seriously affect a student’s academic program. For this reason, the District sponsors an Injury and Sickness Plan that protects the student against the expense of accidents and the expense of illness. Insured students may purchase protection against Injury or Sickness for their dependents. An outline of the coverage is provided in this brochure and we urge each of you to give this plan your careful attention. Alamo Community College District (ACCD)

PLANS AVAILABLE THROUGH ACCD ARE:

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

ELIGIBILITY

Students are eligible if they are enrolled in Plan I - Compulsory Injury Only Plan. Students may purchase protection against Injury & Sickness for their eligible dependents. Eligible dependents are the Insured student’s spouse or unmarried children under the age of 19 years of age who are not self-supporting and who reside with the Insured student; or age 19 or more and primarily supported by the Insured and incapable of self-sustaining employment by reason of mental or physical handicap.

EFFECTIVE AND TERMINATION DATES

This plan covers students and dependents at home, at school, or while traveling, 24 hours a day during the Insured’s Coverage Period.

The Policy will become effective at 12:01 a.m. on August 27, 2006. Coverage becomes effective for an Insured person at 12:01 a.m. on the effective date of the selected Coverage Period as shown on the enrollment form, or the date enrollment form and premium are received, whichever is later.

Coverage terminates for the Insured person at 12:01 a.m. on August 25, 2007, or the end of the Coverage Period for which premium was last paid (as shown on the enrollment form), whichever is earlier.

COVERAGE PERIODS:  
Fall 08/27/07 through 01/08/08
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

ENROLLMENT PROCEDURE

Student Injury only coverage is provided under a separate plan by the Board of Trustees of the Alamo Community College District for each eligible student. The Plan described in this brochure provides Sickness Coverage for those insured students and Injury and Sickness coverage for their eligible dependents. The purchase of this insurance is optional and may only be purchased by completing the attached enrollment form and remitting the correct premium.

Dependent coverage is available only if the student is also insured under this plan and the Compulsory Student Injury Insurance Plan provided by his/her participating College. Coverage may not extend beyond the Insured student’s coverage.

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 online.


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.

Elective Surgery and Elective Treatment includes but is not limited to surgery and/or treatment for acne; acupuncture allergy and allergy vials, including allergy testing; bio-feedback type services; breast implants; breast reduction; circumcision; corns, calluses and bunions; cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under the Policy, and except for cosmetic surgery required to correct a covered Injury or infection or other diseases of the involved part and reconstructive surgery because of congenital disease or anomaly of a covered newborn child for which benefits are otherwise payable under the Policy; deviated nasal septum, including submucous resection and/or other surgical correction; family planning; fertility tests; hair growth or removal; impotence, organic or otherwise; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; learning disabilities; nonmalignant warts, moles and lesions; obesity and any condition resulting therefrom (including hernia of any kind), except for the treatment of an underlying covered Sickness; premarital examinations; preventive medicines or vaccines, except where required for the treatment of a covered Injury; sexual reassignment surgery; sleep disorders, including testing; smoking cessation; tubal ligation; vasectomy; and weight loss or reduction.

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.

SICKNESS means an illness or disease which causes a loss while the Policy is in force and which results in covered medical expenses. All related conditions and recurrent symptoms of the same or a similar condition will be considered the same Sickness. It also includes pregnancy and complications of pregnancy.

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
A. ACCIDENTAL INJURY 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 Physician (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. Outpatient lab and x-ray.
  5. Dental treatment made necessary by Injury to sound, natural teeth. Maximum $250 per tooth.
  6. Ambulance expense.
  7. Prescription drugs when prescribed by the attending Doctor. Maximum $100 for each Injury.

B. SICKNESS MEDICAL EXPENSE:
If a Sickness or disease (which is not a Pre-existing condition) requires treatment, this plan will pay the Usual & Customary Charge, or the amount listed, if less, for Covered Medical Expenses incurred within 52 weeks following the date of the first treatment for the Sickness.

  1. Daily Room and Board when hospital confined up to $200 per day, to a maximum of $3,600.
  2. Miscellaneous Hospital Charges for use of operating room, anesthesia (including administration thereof), X-ray examination (not treatment), laboratory tests, drugs or medicines, therapeutic services or supplies when hospital confined and while receiving Room and Board benefits above, up to a maximum of $1,000.
  3. Hospital Outpatient Expenses (not including drugs and medications) up to $250.
  4. Surgery performed by a licensed Physician, in accordance with relative value studies having a conversion factor of $30 up to a maximum of $5,000. If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed the benefit for the one such procedure for which the largest benefit is payable; (not payable in addition to Physician Visits).
  5. Physician’s Visits beginning with the first visit when hospital confined, up to a $50 per visit per day not to exceed a maximum of $500 for each Sickness; or not hospital confined up to $50 per visit per day, not to exceed a maximum of $500 for each Sickness. Payment shall not be made for: a) manipulation or massage or ; b) medical treatment received on the day of any surgical operation or during convalescence therefrom if a Surgery benefit is payable.
  6. Diagnostic X-Ray and Laboratory Procedures when followed by medical treatment prescribed by the attending Physician for a diagnosed Sickness up to a maximum of $250 each.
  7. Professional Ambulance Expense $150 per trip to a maximum of $300 per Policy period.
  8. Prescription Drugs when prescribed by the attending Physician to a maximum of $100 per Policy period.
     

II. MAJOR MEDICAL COVERAGE SUPPLEMENT

NOTE: The Injury portion of this Major Medical Coverage Supplement is applicable only to dependents since students are covered for injuries under an alternate plan. Sickness benefits apply to both students and dependents.

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 or Sickness. 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 benefits 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

IV. REPATRIATION

Upon receipt of due proof of an Insured person’s death, we will pay the Usual and Customary Charge up to a maximum of $10,000 for the preparation of the deceased’s body for burial or cremation in the Insured’s place of residence, including the cost of embalming and coffin; and transportation of the deceased’s body to his or her home country. Expenses incurred under this coverage must be approved by the Claims Administrator before the body is prepared for transportation.

V. MEDICAL EVACUATION

Upon receipt of due proof that an Insured person incurred expenses for Physician ordered emergency medical evacuation, including medically appropriate transportation and Medically Necessary care en route to the nearest suitable Hospital or to the Insured person's home country, when the Insured person is critically ill or Injured and has been hospital confined for at least 5 days, and appropriate local care is not available, we will pay the Usual and Customary Charge incurred not to exceed $3,000, subject to the prior approval of the Claims Administrator for the Policy and the attending Physician.

PRE-EXISTING CONDITION: No benefits will be payable for the Insured’s Pre-existing Condition's. They are defined as an Injury sustained or a Sickness 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 and 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.

MANDATED BENEFITS: This plan will pay for the following mandated benefits and any other applicable mandate in accordance with Texas insurance laws: Colorectal Cancer; Chemical Dependency Benefit; Prostate Cancer Screening; Low Dose Mammography; Bone Density; TMJ/CMJ; Rehabilitative Treatments and Therapy for an Acquired Brain Injury; Telemedicine or Telehealth Services; Diabetes Supplies, Equipment, and Self-Management Training; Mastectomy and Reconstruction; Outpatient Contraceptive Service; Off-Label Drugs; Postpartum Hospital Stay; Hearing Screening for Children; Serious Mental Health; Craniofacial Abnormalities Benefit; Phenylketonuria (PKU) Benefit; Maternity Length of Stay; and Immunizations.

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.

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, vaccines except antitoxins administered within twenty-four (24) hours after an accident, or prescriptions drugs, 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 diagnose is 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, and routine Papanicolaou cytology test;
  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 Inured 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, except for the correction of birth defects, correction of deformities resulting from cancer surgery, or surgery that is required as a result of an Injury which necessitates medical treatment within 24 hours of the accident. Correction of deviated nasal septum shall be considered as Cosmetic surgery for the purpose of this Policy.

 

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 condition 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:

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

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

PREFERRED PROVIDER NETWORK:

 

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.

Policy Form: SH1000GPM(Rev.2004).TX
Policy No. CTX125D

2394330