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2007 - 2008
Medical Benefit Plan
Coverage is in effect 24 hours a day. For students enrolled during the Fall Semester, coverage will be in effect from either August 27, 2007 or the date of Premium Payment, whichever is later, until August 27, 2008. For students enrolled during the Spring Semester, coverage will be in effect from either January 1, 2008, or the date of Premium Payment, whichever is later, until August 27, 2008. The plan covers injuries sustained and Sickness contracted and causing loss commencing during the coverage period. The policy expires August 27, 2008. (Please note that the Policy cannot establish physician’s fees, and therefore, cannot guarantee that payments made by Monumental Life Insurance Company, hereafter referred to as the Company, will cover all physician and surgeon charges in full.)
Accident Medical Expense Benefits
(All claims are subject to a deductible of $100.)
Benefits are provided up to
$10,000 for accidental injuries for which medical treatment by a physician,
surgeon, dentist,
registered nurse, hospital services, ambulance services, or x-rays are
rendered. The initial treatment must be rendered within 90 days of the
accident and benefits are limited to treatment rendered within 52 weeks of the
date of accident. Specific benefit levels are as shown below:
Hospital Room and Board: The expense actually incurred is allowed not
to exceed $100 per day.
Hospital Inpatient
Miscellaneous Expense: The expenses actually incurred are allowed not to
exceed $1,000 as the
result of any one Injury.
Surgical Expense: The expense actually incurred is allowed not to exceed $70 times the unit value of the 1974 California Relative Value Studies, or $1,000 in total for all surgical operation(s) performed for any one Injury.
Ambulance Expense: The expense actually incurred is allowed not to exceed $200 for any one Injury.
Physician’s Expense: The Usual and Customary Charge is allowed not to exceed $200 for any one Injury.
Registered Graduate Nurse Expense: The expense actually incurred is allowed subject to a maximum benefit of $60 per 24-hour period.
Outpatient Miscellaneous Expense: The expense actually incurred is allowed subject to a maximum $150 as the result of any one Injury.
Dental Expense: The Company will pay up to $500 per tooth for treatment to sound and natural teeth injured in a covered accident.
Physiotherapy Benefit: Up to $25 per visit is allowed subject to a maximum of $250 for any one Injury.
Prescription Drug Expense: The expense actually incurred is allowed up to a maximum of $50 per covered Injury.
Anesthesia Expense: The expense actually incurred is allowed up to 30% of the surgeon’s allowance under the policy subject to a maximum of $300 for any one Injury.
Consultant’s Expense: The expense actually incurred is allowed up to $75 per covered Injury.
Sickness Medical Expense Benefits
(All claims are subject to a deductible of $100)
Sickness benefits will be paid up to $10,000 for medical expenses incurred within 52 weeks of the date of the first medical treatment subject to the following:
Hospital Room and Board: The expense actually incurred is allowed not to exceed $100 per day.
Hospital Inpatient Miscellaneous Expense: The expenses actually incurred are allowed not to exceed $1,000 as the result of any one Sickness.
Surgical Expense: The expense actually incurred is allowed not to exceed $50 times the unit value of the 1974 California Relative Value Studies, or $1,000 in total for all surgical operation(s) performed for any one Sickness.
Ambulance Expense: The expense actually incurred is allowed not to exceed $200 for any one Sickness.
Physician’s Expense: The Usual and Customary Charge is allowed not to exceed $1,000 for any one Sickness subject to the following limitations: Payment will begin with the first call. The allowance will be $35 per visit.
Registered Graduate Nurse Expense: The expense actually incurred is allowed subject to a maximum benefit of $60 per 24-hour period or $600 as the result of any one Sickness.
Outpatient Miscellaneous Expense: The expense actually incurred is allowed subject to a maximum $300 as the result of any one Sickness.
Prescription Drug Expense: The expense actually incurred is allowed up to a maximum of $50 per covered Sickness.
Anesthesia Expense: The expense actually incurred is allowed up to 30% of the surgeon’s allowance under the Policy subject to a maximum of $300 for any one Sickness.
Consultant’s Expense: The expense actually incurred is allowed up to $75 per covered Sickness.
Mental or Nervous Disorders Benefit - The Company will pay for services rendered by a psychiatric consultant (in or out of the hospital) when an Insured is referred for counseling. The Company will pay $25.00 a visit up to a maximum of $250 worth of visits..
Mandated Benefits
The plan will pay benefits for the following mandated benefits and any other applicable mandate in accordance with Pennsylvania insurance laws: Maternity Length of Stay, Mammography Benefit, Women’s Preventative Health Service Benefit including Gynecological Exam and Routine Pap Smears, Childhood Immunizations Benefit, Alcoholism and Drug Treatment Benefits, Mastectomy Reconstruction and Mastectomy Minimum Stays, Chemotherapy, Diabetic Supplies and Equipment, Emergency Services, Serious Mental Illness, Midwife, Newborn Length of Stay, and Metabolic Disease Formula.
Major Medical
For Both Accident and Sickness
After the Company pays $10,000 in
basic benefits under either the accident or Sickness provision of the Policy for
any one accident or Sickness, the Policy will pay 80% of the expenses incurred
in excess of $10,000 up to but not exceeding $15,000 for physician’s services,
hospital confinement, nursing services, x-rays, operating room, emergency room,
anesthesia, laboratory service, dressings, prescription medicines, casts, use of
wheel chair, crutches, or ambulance for any one covered accident or Sickness.
Expenses must be incurred within two years from the date of accident or
Sickness.
The Policy does not cover:
Service or treatment rendered as part of the duties of a physician or any other person employed or retained by
the Policyholder;Injury sustained or caused by any act of war, riots, civil disorders, or commotions;
Eyeglasses, contact lenses, or prescriptions therefor;
Self-inflicted Injuries, suicide, or attempt thereat while sane or insane;
Congenital defect;
Injuries sustained as a result of practice or participating in intercollegiate sports in any form;
Injuries sustained as a result of skiing, unless sponsored scheduled and supervised by the Policyholder;
Injury or Sickness for which the Insured is entitled to benefits under any Worker’s Compensation Act or Law or similar legislation, or medical expenses covered under any Automobile Reparations Reform Act, or Automobile No-Fault Law, or similar legislation;
Any loss sustained or contracted in consequence of the Insureds being intoxicated or under the influence of any narcotic unless administered on the advice of a physician;
Air travel except as a fare-paying passenger on a commercial aircraft;
Health treatment or examinations where no Injury or Sickness is involved;
Elective abortions or any other voluntary termination of pregnancy;
Dental treatment except for Injury to sound, natural teeth;
Treatment in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay;
Elective surgery, or cosmetic surgery unless performed in conjunction with a covered loss;
Services or treatment rendered by a Physician or nurse who is the Insured or a member of his immediate family;
Preventative medicines, serums, or vaccines;
An Insured’s commission of or attempt to commit a felony or to which a contributing cause was the Insured’s being engaged in an illegal occupation.
Claims Procedures
Claim forms containing complete instructions for filing a claim may be obtained at either:
-
Student Life Office, Charles E. Rollins Center, Room 12, or;
Proofs of loss must be submitted within 90 days following the date of accident or start of Sickness.
This Plan is Administered by:
101 JFK PARKWAY
SHORT HILLS, NJ 07078
(866) 267-0092 (Claims/Coverage)
(800) 526-1379 (Other Questions)
Preferred Provider Network:
PLEASE PRINT OUT THIS BROCHURE AND KEEP IT AS A GENERAL SUMMARY OF THE INSURANCE BENEFITS. 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 on this brochure. If any discrepancy exists between the brochure and the Master Policy, the Master Policy will govern and control the payment of benefits.
Policy Form SH3000GPM.PA
