2007 - 2008
International Students
Sickness & Accident Insurance Plan

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, 2009. 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 this 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

Benefits are provided up to $5,000 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 30 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 the Usual and Customary Charge. Surgical Expense: The expense actually incurred is allowed not to exceed the Usual and Customary Charge

Hospital Inpatient Miscellaneous Expense: The expenses actually incurred are allowed not to exceed the Usual and Customary Charge.

Ambulance Expense: The expense actually incurred is allowed not to exceed the Usual and Customary Charge.

Physician’s Expense: The expense actually incurred is allowed not to exceed the Usual and Customary Charge.

Registered Graduate Nurse Expense: The expense actually incurred is allowed not to exceed the Usual and
Customary Charge.

Outpatient Miscellaneous Expense: The expense actually incurred is allowed not to exceed the Usual and Customary Charge.

Dental Expense: The Company will pay up to $1000 for treatment to sound and natural teeth injured in a covered accident.

Physiotherapy Benefit: The expense actually incurred is allowed not to exceed the Usual and Customary Charge.

Prescription Drug Expense: The cost of prescription drugs is payable in full up to $500 (for Injuries and Sicknesses combined) for the policy year. Prescriptions must be filled at an Advance PCS participating pharmacy. Insured persons will be given a prescription card to use at Advance PCS Pharmacies. Until such card is received, you will have to purchase prescriptions and submit a claim form to Bollinger for reimbursement.

Anesthesia Expense: The expense actually incurred is allowed not to exceed the Usual and Customary Charge.

Consultant’s Expense: The expense actually incurred is allowed not to exceed the Usual and Customary Charge.

Sickness Medical Expense Benefits

Sickness benefits will be paid up to $5,000 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% of the semi-private room rate per day for the first 5 days and 80% of the semi-private room rate per day for days 6-60 per Sickness.

Hospital Inpatient Miscellaneous Expense: The expenses actually incurred are allowed not to exceed $1,500 as the result of any one Sickness.

Surgical Expense: The expense actually incurred is allowed not to exceed the Usual and Customary Charge.

Ambulance Expense: The expense actually incurred is allowed not to exceed the Usual and Customary Charge.

Physician’s Expense: The Usual and Customary Charge is allowed not to exceed $350 for any one Sickness.

Registered Graduate Nurse Expense: The expense actually incurred is allowed not to exceed the Usual and Customary Charge.

Outpatient Miscellaneous Expense: The expense actually incurred is allowed subject to a maximum $400 as the result of any one Sickness.

Prescription Drug Expense: The cost of prescription drugs is payable in full up to $500 (for injuries and sicknesses combined) for the policy year. Prescriptions must be filled at an Advance PCS participating pharmacy. Insured persons will be given a prescription card to use at Advance PCS Pharmacies. Until such card is received, you will have to purchase prescriptions and submit a claim form to Bollinger for reimbursement.

Anesthesia Expense: The expense actually incurred is allowed up to 40% of the surgeon’s allowance under the policy.

Consultant’s Expense: The expense actually incurred is allowed not to exceed the Usual and Customary Charge.

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 $45 a visit up to a maximum of $450 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.

Medical Evacuation Benefit

When an Insured incurs expense for his medical evacuation to his/her natural country, the Company will pay for the actual expenses incurred for such evacuation, not to exceed $10,000. The evacuation must be recommended and approved by the attending physician.

Repatriation Benefit

In the event of the death of an Insured, the Company will pay for those incurred expenses up to a maximum of $10,000 for the preparation and transportation of the body to the Insured’s place of residence in his/her home country. This benefit does not include the transportation expense of anyone accompanying the body.

Major Medical

For Both Accident and Sickness

After the Company pays $5,000 in basic benefits under either the accident or Sickness provision of the Policy for any one accident or Sickness, then the Policy will pay 80% of the expenses incurred in excess of $5,000 up to but not exceeding $45,000 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 one year from the date of accident or Sickness.

Exclusions

The Policy does not cover:

1. Service or treatment rendered as part of the duties of a physician or any other person employed or retained by the Policyholder;

2. Injury sustained or caused by any act of war, riots, civil disorders, or commotions;

3. Eyeglasses, contact lenses, or prescriptions therefor;

4. Self-inflicted Injuries, suicide, or attempt thereat while sane or insane;

5. Congenital defect;

6. Injuries sustained as a result of practice or participating in intercollegiate sports in any form;

7. Injuries sustained as a result of skiing, unless sponsored scheduled and supervised by the Policyholder;

8. 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;

9. 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;

10. Air travel except as a fare-paying passenger on a commercial aircraft;

11. Health treatment or examinations where no Injury or Sickness is involved;

12. Elective abortions or any other voluntary termination of pregnancy;

13. Dental treatment except for Injury to sound, natural teeth;

14. Treatment in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay;

15. Elective surgery, or cosmetic surgery unless performed in conjunction with a covered loss;

16. Services or treatment rendered by a Physician or nurse who is the Insured or a member of his immediate family;

17. Preventative medicines, serums, or vaccines;

18. 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:

1. Student Life Office, Charles E. Rollins Center, Room 12, or;

2. By printing one from this link.

Proofs of loss must be submitted within 90 days following the date of accident or start of Sickness.

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

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