IF YOU DO NOT HAVE YOUR OWN INSURANCE AND YOU
ARE A FULLTIME STUDENT, YOU MUST PURCHASE THE COLLEGE SPONSORED PLAN.
THE INSURANCE PREMIUM OF $275.00 IS LISTED ON ALL FULL-TIME TUITION
BILLS AND MUST BE PAID BY AUGUST FIFTEENTH, 2007, UNLESS THE ENCLOSED
WAIVER CARD IS COMPLETED, SIGNED AND RETURNED BY THAT DATE. THE PREMIUM
IS NONREFUNDABLE.
HOOD COLLEGE
FREDERICK, MARYLAND
To Students and Their Parents:
The Hood College Student Health Insurance
Plan covers a student for both Injury and Sickness, 24 hours per
day, 12 months a year, on a world wide basis as well as at the
college.
Adequate insurance for medical expenses
resulting from Injury or Sickness is important. A large medical
bill for which an individual has no insurance could result in a
financial problem that would interfere with the completion of
college education.
The College requires that all full-time
students carry the College sponsored plan or a plan of equal or
better coverage. If you have your own insurance, complete and
return the waiver card included with this brochure.
IF YOU DO NOT HAVE YOUR OWN
INSURANCE, AND ARE A FULL-TIME STUDENT
YOU MUST PURCHASE THE COLLEGE
SPONSORED PLAN.
The enclosed brochure describes the
insurance plan which has been designed to meet the needs of the
students at Hood College. Our plan is underwritten by Peoples
Benefit Life Insurance Company and administered by Bollinger, Inc.
We are pleased to be able to provide you with the opportunity to
subscribe to a health insurance plan designed specifically for
you. Please read it. If you elect the College sponsored plan, keep
the brochure for future reference and cut out and carry the
insurance card for identification to medical providers.
THE INSURANCE PREMIUM OF $275 IS
LISTED ON YOUR TUITION BILL AND MUST BE PAID BY AUGUST 15, 2007.
UNLESS THE ENCLOSED WAIVER CARD IS COMPLETED, SIGNED AND RETURNED
BY THAT DATE, YOU WILL BE BILLED AND THE PREMIUM IS
NON-REFUNDABLE.
COVERAGE
This plan provides protection 24 hours per day
during the term of the policy for each student insured. Students are
covered on and off the campus, at home, or while traveling between home
and college interim vacation periods.
The policy becomes effective August 15, 2007 and
expires August 15, 2008.
After August 15, 2007, the individual student’s
coverage is effective the date his or her premium contribution is paid
and terminates at 12:01 a.m. August 15, 2008.
No individual policies will be issued. Your
cancelled check will be your receipt. The Master Policy will be on file
at the College. Protection is in effect during holiday periods.
For students entering college at Beginning of 2nd Semester . . . . . . . . . . . . . . . . . . $200.00
DEFINITIONS
Hospital means an institution which meets
all the following requirements:
it must be operated according to law;
it must give 24 hour medical care, diagnosis
and treatment
to the sick or injured on an in-patient basis for which a charge is
made;
it must provide diagnostic and surgical
facilities supervised by Physicians;
Registered Nurses must be on 24 hour call or
duty;
the care must be given either on the Hospital’s
premises or in facilities available to the Hospital on a pre-arranged
basis. A Hospital is not a rest, convalescent, extended care,
rehabilitation or skilled nursing facility. It is not a place which
primarily treats mental illness, alcoholism or drug addiction; nor
does it include
any ward, wing or other section of the Hospital that is used for such
purposes. It is not a facility where, in the absence of insurance,
there is no legal obligation to pay.
Injury means bodily injury caused by an
accident. The accident must occur while the Covered 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. The Injury must not be
caused by or contributed to by Sickness.
Sickness means an illness, disease, or
trauma related disorder due to Injury which first manifests or 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
similar condition will be considered the same Sickness. It also includes
Pregnancy and Complications of Pregnancy.
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 death, permanent placement of the Covered
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 Sickness or Injury which fulfills the
above conditions. These expenses will not be paid for minor injuries or
minor
sicknesses.
Medically Necessary means care which a
Physician has determined to be certifiably essential for the diagnosis
or treatment of a Sickness or Injury. This determination must be based
on objective results produced by an examination of the Covered Person’s
demonstrable symptoms. The Physician’s treatment plan may be reviewed by
an impartial third party whose determination will be binding on us 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 and the
MDR(Medical Data Research) schedule of fees.
Elective Surgery means any surgery or
treatment that is not Medically Necessary, including any service,
treatment, or supply that is deemed by us to be research or
experimental; or is not recognized as generally accepted medical
practice in the United States. Elective Surgery and Elective Treatment
do not include any procedure deemed a Medical
Necessity. Elective Surgery does not mean a Cosmetic Procedure required
to correct an Injury for which benefits are otherwise payable under this
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; skeletal
irregularitiesof one or both jaws, including orthognathia and mandibular
retrognathia;
sleep disorders, including testing; smoking cessation; temporomandibular
joint dysfunction (TMJ); tubal ligation; vasectomy; and weight loss or
reduction.
BASIC MEDICAL BENEFITS FOR
ACCIDENTAL Injury
This portion of the plan pays charges for
treatment by doctors or surgeons, for registered nurse service,
ambulance and hospital service, including fees for laboratory, operating
room, anesthetics, medical supplies, x-rays, prescription drugs and
dressings when such charges are incurred within twelve (12) months
following the date of the Injury. The Injury must require treatment
within 30 days of the date of the Injury.
Maximum for any one accident . . . . . . . . . . .$2,000.00
Benefits for dentist charges are payable for
treatment of Injury to sound, natural teeth during the 12 months
following the Injury, if the treatment begins within 30 days after the
date of the accident not to exceed . . . . .$500.00
BASIC Sickness EXPENSE BENEFITS
If Sickness causes loss commencing while the
Policy is in force as to the insured, and such insured required any of
the services listed below, payment will be made for the Usual and
Customary Charges incurred within 52 weeks from the date of first
treatment for Sickness; not to exceed $2,000.00.
Daily Room and Board when hospital confined up
to a maximum per day $1000.00
Miscellaneous Hospital Charges for use of the
operating room (in or out), anesthesia, 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 . . . . . . . . . . . . . . .
. . .$750.00
Physician’s Visits when Hospital confined or
not; beginning with the first visit, 1 visit per day per visit . . . .
. . . . . . . . . . . . . . . . . . . . . . . . .$50.00
up to a maximum of . . . . . . . . . . . . . . . . . . .25 days
Surgical Operations performed by a licensed
Physician; in accordance with the Ingenix Table using a conversion
factor of $75,
maximum of . . . . . . . . . . . . . . . . . . . . . . .$1,000.00
Consultant Fees/Second Opinion when such
services are deemed necessary by the attending Physician for the
purpose of confirming or determining a diagnois (not treatment);
up to a maximum of . . . . . . . . . . . . . . . . . .$75.00
Professional Ambulance Service to and from
Hospital
confinement;
up to a maximum of . . . . . . . . . . . . . . . . . .$125.00
Registered Nurse Services (other than a nurse
who ordinarily resides in the Insured’s household or who is related by
blood, marriage or legal adoption to the insured) where the Insured
has Room and Board benefits payable and the services are ordered by a
Physician.
Diagnostic X-ray, Lab Procedures and Emergency
Treatment (outpatient) when followed by medical treatment prescribed
by the attending Physician;
up to a maximum of . . . . . . . . . . . . . . . . . .$850.00
Anesthetist Services based upon the surgeon’s
fee allowance for the operation;
up to a maximum of . . . . . . . . . . . . . . . . . . . . .25%
Drugs and Medications when prescribed by a
Physician, maximum per year . . . . . . . . . . . .$100.00
Mental and Nervous Disorder benefit when the
insured person incurs medical expense for treatment of a mental or
nervous disorder, benefits for such expense will be covered as any
other illness, but not to exceed for inpatient expenses, a maximum of
30 days in any policy year under Basic &Major Medical Coverage.
Schedule of
MAJOR MEDICAL EXPENSE BENEFITS
Major Medical Maximum . . . . .
. . . . . $65,000
The Deductible Amount . . . . . . . . . . . . .
. . . . .$2,000 Benefits become payable when covered Medical Expenses exceed the
Basic Benefits Maximum.
Average Semiprivate Hospital charges for room and board and general nursing services in
excess of this amount are not counted as covered Medical Expenses.
Insured Proportion . . . . . . . . . . . . . .
. . . . . . . . . .80% Benefits will be paid for this percentage of the Covered Medical
expenses which exceed the Deductible Amount, subject to the Maximum
Benefit. Except that the insured proportion of the expenses for
Psychiatric treatment or consultation because of a mental or nervous
condition while
the individual is not confined to a hospital will be limited to 50%.
Benefit Period 12 months from the date of Injury or the first treatment for
Sickness.
Upon receipt of due proof of a Covered Person’s
death, we will pay the actual charges for the preparation and
transportation of the body to his/her home country or country of regular
domicile subject to the approval of the Claims Administrator of the
Policy. If applicable, such action will be in accordance with any
international standards. The benefit payable is not to exceed $3,000 and
death must occur at least 100 miles away from Covered Person’s city of
residence. Benefits provided by this provision are paid in addition to
any other benefits payable under the Policy.
NON-DUPLICATION OF BENEFITS
The Policy provides benefits in accordance with
all of its provisions only to the extent that benefits are not provided
by any Other Valid and Collectible Insurance. If the Covered Person is
covered by Other Valid and Collectible Insurance, all benefits payable
by such insurance will be determined before benefits will be paid by
this Policy. This Policy is the second payor to any other insurance
having primary status or no coordination or non-duplication of benefits
provision.
If the Covered Person is insured under group or
blanket insurance which is also excess to other coverage, this Policy
pays a maximum of 50% of the benefits otherwise payable.
Benefits paid by this Policy will not exceed:
any applicable Policy maximums; and
100% of the compensable expenses incurred when
combined with benefits paid by any Other Valid and Collectible
Insurance.
PRE-EXISTING
CONDITION LIMITATION
No benefits will be payable for the Insured’s
Pre-existing Conditions. They are defined as an Injury sustained or a
Sickness for which the Insured noticed symptoms or was medically
diagnosed, treated including medication, or advised by a Physician
within the twelve months immediately prior to his Effective Date of
Coverage under this Policy. Covered Medical Expenses resulting form a
Pre-existing Condition will not be covered unless:
Twelve consecutive months have elapsed during
which no medical treatment or advice is given by a Physician for such
condition; or
The insured has been insured under this Policy
and
the college’s prior policies for two continuous years; or
The Insured has been receiving benefits under
the college’s
prior policies and has been continuously insured since the date of
accident, Injury, or Sickness, whichever occurs first.
EXCLUSIONS
Surgical, medical or other services when
performed to treat work related illness, conditions or injury whether
or not covered by Worker’s Compensation.
Dental or periodontal treatment, except
treatment resulting from an accident resulting from Injury outside the
mouth; dental Injuries incurred while eating or biting down are not
covered.
Injury sustained or Sickness contracted 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.
Eyeglasses, radial keratotomy, contact lenses,
hearing aids or prescriptions or examinations except as required for
repair caused by a covered Injury.
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.
Cosmetic surgery, except for the correction of
birth defects, correction of deformities resulting from cancer
surgery, reconstructive breast surgery on either or both breasts, 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.
Suicide, attempted suicide or intentionally
self-inflicted Injury while sane or insane (in Colorado and Missouri,
while sane).
Services that are provided normally without
charge by the University’s health center, infirmary or Hospital; or by
any person employed by the University.
Routine physical examinations, preventative
testing or treatment screening exams or testing in the absence of
Sickness or Injury, (except osteoporosis prevention and treatment,
colorectal or prostate cancer screening), premarital
examinations, pre-employment examinations, health examinations or
pre-school physical examinations and any associated laboratory work,
not including mammograms and routine Papanicolaoucytology test.
Abortion, unless the life of the mother would
be endangered if the fetus would be carried to term.
Expenses incurred for experimental infertility
procedures and fertility tests unless caused by Sickness or Injury.
Elective Surgery or Elective Treatment.
MANDATED BENEFITS
The plan will pay for the following mandated benefits and any other
applicable mandate in accordance with Maryland insurance laws: Home
Health Care; Diabetes Supplies; Equipment and Self-Management Training;
Enteral Formulas Benefit; Maternity Benefit; Mammography
Benefit; Dental General Anesthesia Benefit; Prostate Cancer Screening
Benefit; Infertility Benefit; Scalp Hair Prosthesis Benefit;
Reconstructive Breast Surgery Benefit; Osteoporosis Prevention and
Treatment; Clinical Trials Benefit; Chlamydia Screening Benefit;
Mastectomy and Testicular Surgery Benefit; Mastectomy Prosthetic Device
Benefit; Treatment of Morbid Obesity; Blood and Blood Plasma; Colorectal
Cancer Screening; Contraceptive Drugs; and Off-Label Drugs.
PREFERRED PROVIDER ORGANIZATION
First Health, a national network of hospitals and
physicians is available for your use. Use of the PPO is not mandatory,
however, use of the First Health
network will help minimize your out-of-pocket
costs.
To find a Network Provider in your area, log on to
the First Health Provider link from the Student Insurance website at
www.BollingerInsurance.com/hood or call First Health at (630)
737-7900.
CLAIM PROCEDURES
In the event of financial loss caused by a covered
Injury or Sickness, the student should:
Secure a Company claim form from the claims
administrator
named below, or from the school, or from TIA, Inc. No claim will be processed without a completed
claim form.
Follow the instructions on the front of the
claim form.
File claims within 30 days of Injury or first
treatment for a Sickness. Bills must be received by the claims
administrator within 90 days of service or as soon as reasonably
possible to be considered for payment. Bills submitted after one year
will not be considered for payment except in the absence of legal
capacity.
SUBMIT ALL CLAIMS OR INQUIRES
TO:
P.O. BOX 727
SHORT HILLS, NJ 07078-0727
1-866-267-0092 (Claims/Coverage)
1-800-526-1379 (Other Questions)
PREFERRED PROVIDER NETWORK:
1-800-226-5116
THIS PLAN IS UNDERWRITTEN BY
PEOPLES BENEFIT LIFE
INSURANCE COMPANY
CEDAR RAPIDS, IOWA
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.
If any discrepancy exists between the Brochure and the Master Policy,
the Master Policy will govern and control the payment of benefits.