2007 COVERAGE
INTRODUCTION
This insurance plan was designed and is endorsed and recommended by Columbia International University for all eligible students and their eligible dependents. Many students and their dependents will require health care at some time during the school year.
ELIGIBILITY
All students enrolled at Columbia International University are included in this insurance plan and the premium for coverage is added to the tuition billing unless proof of comparable coverage is furnished.
REFUND PROVISION
In the event an Insured person leaves school to enter active military service, coverage will cease and a pro rata refund of premium will be made upon request.
TERMS OF COVERAGE
The Policy for the current year becomes effective on August 11, 2007 at 12:01 a.m. and continues until 12:01 am on August 11, 2008. (Fall effective 8/11/07 - 1/9/08; Spring effective 1/9/08 - 8/11/08). Coverage remains in effect during holiday and vacation periods. Should an Insured person graduate or withdraw from the institution, the insurance shall remain in effect until the end of the period for which premium has been paid.
WAIVER DEADLINE
If you have proof of comparable insurance and wish to waive coverage, the deadline to waive out of this plan is the last day of the Registration Period.
| ANNUAL | FALL | SPRING | |
| Student | $725 | $302 | $423 |
| Spouse | $1,815 | $756 | $1,059 |
| Dependent | $1,030 | $429 | $600 |
DEFINITIONS
INJURY means bodily injury caused by an accident. 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.
DEDUCTIBLE means the dollar amount of Covered Medical Expenses that must be paid as an out-of pocket expense by each Covered Person per Injury or Sickness each Policy Year before benefits are payable under this Policy.
HOSPITAL means an institution which meets all of the following requirements:
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.
INSURED means an eligible student as outlined in this Policy and in the Master Application for whom an application has been received and has paid the required premium. The words he, his, and him refer to the Insured regardless of gender.
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.
PHYSICIAN means a person licensed by the state in which he is resident to practice the healing arts. He must be practicing within the scope of his license for the service or treatment given. He may not be the Insured or a member of his Immediate Family.
SICKNESS means an illness, [or] disease 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.
EXTENSION OF BENEFITS AFTER TERMINATION
The coverage provided under this Policy ceases on the termination date. However, if under the care and treatment of a Physician, benefits will be provided for a Covered Person for up to 9 months past the expiration date of the Covered Person's coverage under this Policy. The total payments made in respect of the Covered Person for each condition both before and after the termination date will never exceed the maximum benefit.
PRE-EXISTING CONDITION LIMITATION
No benefits will be payable for the Insured's Preexisting Conditions. They are defined as an Injury sustained or a Sickness for which the Insured was medically diagnosed, treated (including medication), or advised by a Physician within the six (6) months immediately prior to his Effective Date of Coverage under this Policy.
Covered Medical Expenses resulting from a Preexisting Condition will not be covered unless:
six (6) consecutive months have elapsed during which no medical treatment or advice is given by a physician for such condition ending after the effective date of coverage; or
the Insured has been insured under this Policy and the University's prior policies for six (6) consecutive months; or
The insured has been receiving benefits under the University's prior policies and has been continuously insured since the date of Injury or Sickness, whichever occurs first.
CREDIT FOR PRIOR COVERAGE
This Policy provides portability of coverage as it relates to “pre-existing conditions”. The pre-existing condition limitation set forth in this Policy will be reduced to the extent an Insured Person was covered under a Qualifying Previous Coverage if: 1) the person is not a late enrollee; and 2) the prior coverage was continuous to a date not more than 63 days prior to the effective date of the new coverage, exclusive of any applicable waiting period.
Any pre-existing limitation is reduced by the aggregate of the periods of creditable coverage, if any, applicable to the Insured Person as of the enrollment date, for similar services covered under this Policy and the prior coverage.
DESCRIPTION OF BENEFITS SECTION 1 BASIC ACCIDENT & SICKNESS EXPENSE BENEFITS
When you suffer a loss from Injury or Sickness, we will pay the Expense incurred up to a maximum of $1,000. Benefits are allocated as follows
HOSPITAL ROOM AND BOARD EXPENSE: When your Injury or Sickness requires Hospital confinement, we will pay the Hospital room and board expense up to the semi-private rate, not to exceed $150 per day.
HOSPITAL MISCELLANEOUS EXPENSE: We will pay Expenses incurred by you during a Hospital confinement or as an outpatient for day surgery up to a maximum of $500. We will pay for anesthesia, operating room, laboratory tests, x-rays, oxygen, drugs, medicines, dressings, and other necessary non-room and board Expenses.
SURGICAL EXPENSE: When your Injury or Sickness requires surgery, we will pay 80% of the Expense based upon the MDR (Medical Data research) survey of surgical fees valued at the 90th percentile.
Only one surgical procedure will be covered when multiple procedures are performed, unless Medically Necessary.
If the surgery requires the services of an anesthetist, who is not employed or retained by the Hospital in which the surgery is performed, we will pay the Loss incurred up to a maximum of $250.
If the surgery requires the services of an assistant surgeon, we will pay the Loss incurred up to a maximum of $200.
IN-HOSPITAL PHYSICIAN’S FEES EXPENSE: If while confined to a Hospital, your Injury or Sickness requires the services of a Physician, we will pay the Expense for such services, up to $50 per visit.
OUTPATIENT PHYSICIAN FEES EXPENSE: When Your Injury or Sickness requires the services of a Physician, while not confined to a Hospital, we will pay the Expense up to a maximum of $60 per visit, after a $20 deductible per visit.
AMBULANCE EXPENSE: When you require the use of an ambulance or air ambulance, we will pay the Expense up to a maximum of $100.
OUTPATIENT DIAGNOSTIC X-RAY AND LABORATORY EXPENSE: When your Injury or Sickness requires diagnostic x-ray or laboratory services, under the Physician’s direction, we will pay the Expense up to a maximum of $300.
HOSPITAL OUTPATIENT EXPENSE: When your Injury or Sickness requires the use of outpatient facilities of a Hospital for an emergency room, under the Physician’s direction, we will pay the Expense up to a maximum of $100.
OUTPATIENT PSYCHIATRIC EXPENSE: If, while not confined to a Hospital, your Sickness requires the services of a licensed psychiatrist or licensed psychologist, we will pay the Expense up to a maximum of $60 per visit, up to a maximum of $300 per policy year.
OUTPATIENT PRESCRIBED MEDICINES EXPENSE: When your Injury or Sickness requires prescribed medicines, we will pay the Expense up to a maximum of $40. This shall include coverage of a drug approved by the United States Food and Drug Administration, if the prescription drug has been recognized as safe and effective for treatment of that standard medical reference compendia or medical literature.
SECTION II ACCIDENTAL DEATH & DISMEMBERMENT
Accidental Death and Dismemberment Insurance covers you for a Loss as shown below. The Loss must result from an Accident, directly and independently of all other cases. The Accident must take place while you are Insured under this policy. Also, the Loss must take place within fifty-two (52) weeks after the Accident.
The following table shows the amounts we will pay:
| For Loss of life ......................................................................... | $1,000 |
| Both hands or both feet or sight of both eyes ................................ | $1,000 |
| One hand and one foot .............................................................. | $1,000 |
| One hand and sight of one eye .................................................... | $1,000 |
| One foot and sight of one eye ..................................................... | $1,000 |
| One hand or one foot or sight of one eye ...................................... | $500 |
| The most we will pay for all Losses as the result of one Accident is $1,000. | |
Loss to hands and feet means severance at or above the wrist or ankle joints. Loss of sight means total and irrecoverable loss of sight.
SECTION III SUPPLEMENTAL EXPENSE BENEFIT
If the covered medical Expense for your Injury or Sickness exceeds the aggregate maximum we owe under the basic Accident or basic Sickness benefits, we will pay 80% of the Expense up to a maximum of $49,000. Covered Expenses for daily Hospital room and board will not be more than the usual semi-private room charge.
MANDATED BENEFITS
The plan will pay for the following mandated benefits and any other applicable mandate in accordance with South Carolina insurance laws: Diabetes Supplies, Equipment, and Self-Management Training; Mastectomy; Breast Reconstruction and Prosthetic Devises; and Cancer diagnosis (Mammography, Cytological Screening, Prostate Cancer Screening, Pap Smear).
REPATRIATION OF MORTAL REMAINS (Preparation and Transportation of Remains)
When as a result of a covered Injury or Sickness, you (or your covered dependent) dies while insured under this policy, we will pay the actual Expense incurred for preparation and transportation to your home country (in accordance with the applicable international requirements.) the remains of the deceased's body but not to exceed $50,000 in the aggregated for this benefit and the Medical Evacuation/Repatriation Benefit. This benefit is payable in addition to all the other benefits in this policy.
MEDICAL EVACUATION/REPATRIATION
When as a result of a covered Injury or Sickness, you (or your covered dependent) are hospitalized for five consecutive days or more. We will pay for the evacuation of you or your dependent to your home country, or to a facility operated pursuant to the law for the care and treatment of injured or ill persons. The evacuation will require the recommendation and approval of the attending Physician. We will pay the actual Expense incurred, but not to exceed $50,000 in the aggregate for this benefit and the Repatriation of Mortal Remains benefit. This benefit is payable in addition to any other benefit of this policy.
EXCLUSIONS
Expenses incurred as the result of dental treatment, except as specifically provided for treatment resulting from Injury to natural teeth and congenital cleft lip and palate;
Services that are provided normally without charge by the University's health center, infirmary or Hospital; or by any person employed by the University;
Eyeglasses, radial keratotomy, contact lenses, hearing aids or prescriptions or examinations except as required for repair caused by a covered Injury;
Routine physical examinations, preventive testing or treatment, screening exams or testing in the absence of Sickness or Injury, pre-marital examinations, pre-employment examinations, health examinations or preschool physical examinations including routine care of new born infant, well baby nursery and related Physician charges, and any associated laboratory work, not including mammograms and routine Papanicolaoucytology test;
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;
Elective abortion;
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;
Declared or undeclared war, riot, civil disorder, civil commotion or acts of terrorism;
Suicide, attempted suicide or intentionally self-inflicted Injury while sane or insane (in Colorado and Missouri, while sane);
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;
Injury or Sickness for which benefits have been paid under any Worker’s Compensation or Occupational Disease Law;
Accident sustained or Sickness contracted as a result of the use of alcohol or drugs, medicines or narcotics, unless taken on the advice of a Physician;
Treatment provided in a government hospital unless there is a legal obligation to pay such charges in the absence of other insurance;
Injury resulting from the playing, practice, participating, or conditioning in any intercollegiate contest or competition sponsored by the University, any professional or semi-professional sport, or Injury sustained while traveling to or from such sport, contest or competition as a participant;
CLAIM FILING PROCEDURES
In the event of an Injury or Sickness, in a non-emergency situation, the Insured Person should:
Pick up a claim form from the Health Services Office, or contact the Plan Administrator (see below).
The claim form must be completed and signed. Written proofs of loss (itemized bills) must be furnished with the claim within 90 days from the date of loss. Mail the claim to the address on the form.
Preauthorization and precertification of the benefits to providers of medical service are not required nor provided by us.
Questions concerning claim procedures should be referred to the Plan Administrator. Claim forms are available here.
SUBMIT ALL CLAIMS OR INQUIRIES TO:
101 JFK PARKWAY
SHORT HILLS, NJ 07078
(866) 267-0092 (Claims/Coverage)
(800) 526-1379 (Other Questions)
This Plan is Underwritten By:
Monumental Life Insurance
Company
Cedar Rapids, Iowa
Local Broker:
James L. Shull, CLU
(803) 788-4058
Preferred Provider Network
www.firsthealth.com/ccnUsa/ed/index.html
1-800-226-5116
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.
This brochure is based on Policy #CSC104D 1186756
