YOUR COVERAGE    

IMPORTANT:
Requires Your Attention

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.

PREMIUM RATES

For 12 month period . . . . . . . . . . . . . . . . . . . . . . . $275.00

For students entering college at
Beginning of 2nd Semester . . . . . . . . . . . . . . . . . . $200.00

DEFINITIONS

Hospital means an institution which meets all the following requirements:

  1. it must be operated according to law;
  2. 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;
  3. it must provide diagnostic and surgical facilities supervised by Physicians;
  4. Registered Nurses must be on 24 hour call or duty;
  5. 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.

  1. Daily Room and Board when hospital confined up to a maximum per day $1000.00
  2. 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
  3. 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
  4. Surgical Operations performed by a licensed Physician; in accordance with the Ingenix Table using a conversion factor of $75,
    maximum of . . . . . . . . . . . . . . . . . . . . . . .$1,000.00
  5. 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
  6. Professional Ambulance Service to and from Hospital
    confinement;
    up to a maximum of . . . . . . . . . . . . . . . . . .$125.00
  7. 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.
  8. 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
  9. Anesthetist Services based upon the surgeon’s fee allowance for the operation;
    up to a maximum of . . . . . . . . . . . . . . . . . . . . .25%
  10. Drugs and Medications when prescribed by a Physician, maximum per year . . . . . . . . . . . .$100.00
  11. 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.

Aggregate Policy Maximum . . . . . . . . . . . . . . .$65,000

REPATRIATION BENEFIT

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:

  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 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:

  1. Twelve consecutive months have elapsed during which no medical treatment or advice is given by a Physician for such condition; or
  2. The insured has been insured under this Policy and
    the college’s prior policies for two continuous years; or
  3. 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

  1. Surgical, medical or other services when performed to treat work related illness, conditions or injury whether or not covered by Worker’s Compensation.
  2. 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.
  3. 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.
  4. Eyeglasses, radial keratotomy, contact lenses, hearing aids or prescriptions or examinations except as required for repair caused by a covered Injury.
  5. 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.
  6. 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.
  7. Suicide, attempted suicide or intentionally self-inflicted Injury while sane or insane (in Colorado and Missouri, while sane).
  8. Services that are provided normally without charge by the University’s health center, infirmary or Hospital; or by any person employed by the University.
  9. 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.
  10. Abortion, unless the life of the mother would be endangered if the fetus would be carried to term.
  11. Expenses incurred for experimental infertility procedures and fertility tests unless caused by Sickness or Injury.
  12. 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:

  1. 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.
  2. Follow the instructions on the front of the claim form.
  3. 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.

This brochure is based on Policy # CMD104D

Policy form NHG-MP-400

867425

 


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