Coverage
ELIGIBILITY
All students enrolled for at least 6 hours of
course work attending Northern Kentucky University are eligible to
participate in this insurance program.
Students may also purchase dependent coverage.
Eligible dependents are the spouse (residing with the insured
student) and unmarried child(ren) under nineteen years of age, who
are not self-supporting and reside with the insured student or
“Newborn” child(ren) who are covered for treatment of an Injury or
Sickness (excluding routine hospital, nursery and Physician charges)
from birth until 31 days old. Coverage for newborns will continue
provided Monumental Life Insurance Company, hereafter referred to as
the Company, is notified in writing within 31 days from the date of
birth and by payment of the additional premium.
EFFECTIVE DATE OF COVERAGE
This plan, subject to the benefits and exclusions
outlined in this brochure, protects the Insured Student and his or
her insured dependents at home, at school, or while traveling - 24
hours a day - anywhere in the world during the period for which
premium has been paid, including all interim vacation periods.
Benefits become effective August 14, 2007, or the date following the
postmark on the envelope containing your payment, whichever last
occurs, and continue during the period for which the premium has
been paid. The Master Policy expires at 12:01 AM on August 14, 2008.
Students purchasing coverage by Semester must
submit another enrollment form to renew coverage for each Semester.
In order to maintain continuous coverage, payment must be received
prior to the start date of each Semester.
TERMINATION DATE
Coverage for an Insured Student shall terminate
on the earliest of:
-
the last day of the period for which premium has
been paid; or
-
12:01 AM on August 14, 2008.
Coverage for any dependent shall terminate as
indicated above or on the time and date the Insured Student’s
insurance terminates, whichever is later.
In the event a student enters military service,
coverage will cease and a pro-rata refund of premium will be made
upon request..
NO OTHER REFUNDS WILL BE MADE
CONTINUATION OF COVERAGE
An Insured whose coverage terminates may continue
coverage for an additional 9 months by securing an enrollment form
from the Health Service Office (UC300) or the Plan Administrator
(Bollinger). The enrollment form and premium must be received by the
Plan Administrator (Bollinger) within 30 days after coverage for the
Insured has terminated.
PREMIUM RATES
| |
Annual
Term |
Fall
Semester |
Spring
Semester |
Summer
Semester |
8/14/07-
8/14/08 |
8/14/07-
1/04/08 |
1/04/08-
5/8/08 |
5/8/08-
8/14/08 |
Student
Only |
$ 575.00 |
$209.00 |
$209.00 |
$158.00 |
Student &
Spouse |
$2,085.00 |
$754.00 |
$754.00 |
$586.00 |
Student,
Spouse, &
Children |
$3,247.00 |
$1,193.00 |
$1,193.00 |
$930.00 |
Student &
Children |
$1,738.00 |
$646.00 |
$646.00 |
$500.00 |
MEDICAL EXPENSE BENEFITS SCHEDULE
Benefits are payable for eligible Usual and
Customary medical expenses resulting from a covered accidental
bodily injury, when the first treatment is received within 30 days
after the Injury, or resulting from treatment for a covered Sickness
treated while the Insured’s coverage is in effect, and any follow-up
covered expense incurred within the term of the Policy. Covered
expenses, as listed below, must be for treatment by or under the
order of a licensed Physician and will not exceed the aggregate or
maximum allowed by the policy per covered Injury or per covered
Sickness, as described below:
SICKNESS MEDICAL EXPENSE
INPATIENT BENEFITS
Room & Board Expense: including general nursing care - up
to the semi-private room rate/45 Days Maximum
Hospital Miscellaneous Expenses: for services and supplies
such as:1) the cost of an operating room; 2) laboratory tests; 3)
X-ray examinations; 4) anesthesia; 5) drugs or medicines (excluding
take home drugs); 6) therapeutic services; 7) pre-admission testing;
etc.
. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .
$600.00 Maximum
Surgery: . . . . . . . . . . . . . . . . . . . . . . .. . . .
. $1,000.00 Maximum
Physician’s Visits: One visit per day when a surgery benefit
is not paid, up to . . . . . . . . . . . . . . . . . . . . . . . . .
. .$40.00 Per Visit to an
$800.00 Maximum
Anesthetist Services: Covered under Hospital Miscellaneous
Expenses when in conjunction with surgery.
Psychotherapy: treatment prescribed by a legally qualified
psychiatrist or clinical psychologist for mental disorders, nervous
disorders, alcoholism or drug addiction will be covered as any other
Sickness/$1,000.00 Maximum
OUTPATIENT BENEFITS
Physician Visits . . . . . . . . . . . . . . . . . . .
.$40.00 per visit beginning with the second visit (first visit when
referred by NKU Health Services Nurse Practitioner) up to a Maximum
of $1,000.00
Surgery: Physician’s fees for a surgical procedure will be
paid in accordance with the Medicode, Inc. Schedule, having $100.00
Conversion Factor to a . . . . .$1,000.00 Maximum
Day Surgery Miscellaneous: when surgery is performed in a hospital
emergency room, trauma center, physician’s office, outpatient
surgical center or clinic, for services and supplies such as: 1)
operating room; 2) laboratory tests; 3) X-ray examinations; 4)
anesthesia; 5) drugs or medicines; and 6) therapeutic services
(excluding physiotherapy); etc. . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . $750.00 Maximum
Anesthetist Services: in conjunction with surgery - Paid
under Day Surgery Miscellaneous.
Outpatient Miscellaneous Benefit: includes Medical
Emergency Expenses incurred in a hospital emergency room, surgical
center, or clinic; Diagnostic X-ray Services and Laboratory
procedures, when prescribed by the attending physician . . . . . . .
. .$500.00 Maximum
Mental & Nervous, Alcoholism: maximum of 30 days per
Benefit Period, covered as any other Sickness . .up to
$1,000.00 Maximum
Ambulance Service: for transportation to or from a
hospital ...$250.00 Maximum
OTHER BENEFITS
Prescription Drug: . . . . ..$500.00 Maximum per
Sickness or Injury
INJURY MEDICAL EXPENSE
Paid on an unallocated basis for each covered
Accident for expenses incurred for treatment by a legally qualified
Physician, dentist or surgeon, Hospital confinement, the services of
registered graduate nurse, X-ray service, use of operating room,
anesthesia, laboratory service, surgical dressings, medications,
physiotherapy, plaster casts, use of wheelchair, crutches, or
ambulance, an Aggregate Maximum of $2,000.00 will be paid.
Dental Injury:
Payments will be made only for Injury to sound,
natural teeth . . . . . . . . . . . . . . . . . . . . .. . . .
.up to a maximum of $1,000.00 per tooth
|
MANDATED BENEFITS
The plan will pay for the following mandated
benefits and any other applicable mandate in accordance with
Kentucky insurance laws: Mammography Benefits, Mastectomy
Reconstruction, Mental Health and Illness, and Bone Marrow
Transplants.
MAJOR MEDICAL SUPPLEMENT
When benefits of at least $2,000 have been paid under the Base
Plan, and after a $200 deductible per Sickness or Injury, the
Company will pay 70% of the Usual and Customary medical expenses
which exceed the benefits paid under the Base Plan and which are
incurred during the Benefit Period. A maximum of $20,000 for all
benefits under both the Base Plan and this Major Medical Supplement
will be allowed. Hospital room and board benefits are limited to the
semi-private rate.
ACCIDENTAL DEATH AND DISMEMBERMENT
For accidental death within 100 days of the date of the date of
the accident, or dismemberment within 100 days from the date of
covered Injury, the Plan will pay, in addition to the medical
benefits provided herein, one of the following:
Accidental Death . . . . . . . . . . . . . . . . . . . . .
.$2,000.00
Accidental Loss of:
Both Hands, Feet or Eyes . . . . . . . . . . . . . . . . . .$1,000.00
One Hand and One Foot . . . . . . . . . . . . . . . . . . .$1,000.00
Hand or Foot and One Eye . . . . . . . . . . . . . . . . .$1,000.00
Either Hand or Foot . . . . . . . . . . . . . . . . . . . . .
.$500.00
Sight of One Eye . . . . . . . . . . . . . . . . . . . . . . .
.$500.00
Only one of the amounts shown above, the largest, will be paid
for loss resulting from any one accident, and shall be in addition
to any other indemnity payable for such accident. Loss shall mean in
regard to Hand or Hands or Foot or Feet, actual severance through or
above the wrist or wrists or ankle or ankles, and loss of sight of
eye or eyes shall mean the irrecoverable loss of the entire sight
thereof.
DEFINITIONS
Dependent means the Insured’s spouse unless they are
legally separated; the Insured’s unmarried children under age 19; or
23 if a full-time student; and children whose support is required by
a court decree. Children include natural children, stepchildren, and
legally
adopted children. Newborn children are covered immediately from
birth. They must be primarily dependent on the Insured for support
and maintenance and must live in a parent-child relationship with
the Insured. A spouse who is covered under the Policy as an Insured
will not be eligible as a Dependent. If a husband and wife are both
insured as Students, a child will be the Dependent of only one.
Covered Person means the Insured or a Dependent for whom
an application has been received and the required premium has been
paid.
Injury means bodily injury caused by an accident. The
accident
must occur while the insured’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.
Sickness means an illness or disease which first manifests
itself while the Policy is in force 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 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).
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.
Covered Services means services by or under the direct
supervision of a Physician or licensed psychologist, when performed
in physician’s or licensed psychologist’s office, Hospital, in a
community mental health facility or in an alcoholism treatment
facility.
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
procedures deemed a Medical Necessity. Elective Surgery does not
mean a Cosmetic Procedure required to correct an Injury for which
benefits are otherwise payable under the Policy.
Elective Surgery and Elective Treatment includes but is not
limited to surgery and/or treatment for acupuncture; allergy and
allergy vials, including allergy testing; biofeedback type services;
birth control; 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; preventative medicines or vaccines, except where
required for the treatment of a covered Injury; sexual reassignment
surgery; skeletal irregularities of one or both jaws, including
orthognathia and mandibular retrognathia; sleep disorders, including
testing; smoking cessation; tubal ligation; vasectomy; and weight
loss or reduction.
PRE-EXISTING CONDITIONS
No benefits will be payable for the Insured’s Pre-Existing
conditions. They are defined as an Injury sustained or a Sickness
for which a Covered Person noticed symptoms or was medically
diagnosed, treated (including medication) or advised by a Physician
within the six months immediately prior to his Effective Date of
Coverage under this Policy. Covered Medical Expenses resulting from
a Pre-Existing condition will not be covered unless:
- six 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 the immediate prior year; 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
Benefits will not be paid under this plan for expenses which
result from:
- Services that are provided normally without charge by the
University’s Health Center, infirmary or Hospital, or by any
person employed by the University.
- Congenital conditions, except for Newborn Children insured
under the Policy;
- Elective Surgery and Elective Treatment;
- Preventative medicines, vaccines except anti-toxins
administered within twenty-four (24) hours after an accident, or
prescription drugs, or injections administered during an
outpatient visit, except an injection given by a Physician in
private practice who will certify that a Medical Emergency was
required for the condition;
- 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 pre-school physical examinations including
routine care of a newborn infant, well baby nursery and related
physician charges and any associated laboratory work;
- Eyeglasses, radial keratotomy, contact lenses, hearing aids or
prescriptions or examinations except as required for repair
caused by a covered Injury.;
- Accident sustained or Sickness contracted as a result of the
use of alcohol or the misuse of drugs, medicines, or narcotics,
unless taken in the dosage and for the purpose prescribed by
the Covered Person’s Physician;
- Treatment for mental or emotional disorders (except as
specified in the Benefits Schedule);
- Suicide, attempted suicide or intentionally self-inflicted
Injury while sane or insane (in Colorado and Missouri, while
sane);
- Committing or attempting to commit an assault or felony; or
fighting, except in self defense;
- Declared or undeclared war, riot, civil disorder, civil
commotion or acts of terrorism.;
- Elective abortions;
- Dental treatment, except as specifically provided for
treatment resulting from Injury to natural teeth;
- Riding as a passenger or otherwise in any vehicle or device
for aerial navigation, except as fare-paying passenger in an
aircraft operated by a commercial scheduled airline. This
exclusion does not apply to insured students while taking flight
instruction for University credit.
- 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;
- Travel in or on any two or three wheeled motorized or engine
driven vehicle;
- Injury or Sickness for which benefits are payable under any
Worker’s Compensation or Occupational Disease Law;
- 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;
- 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.
CREDIT FOR PRIOR COVERAGE
The Policy provides portability of coverage as it relates to
“pre-existing conditions”. The pre-existing condition limitation set
forth in the Policy will be reduced to the extent an Insured Person
was covered under qualifying previous coverage if:
- the person is not a late enrollee; and
- 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
the Policy and the prior coverage.
RIGHT OF SUBROGATION
We will be fully and completely subrogated to the rights of a
Covered Person against parties who may be liable to provide
indemnity or make a contribution with respect to any matter that is
the subject of a claim under the Policy.
The Covered Person further agrees to cooperate fully with us in
seeking such indemnity or contribution including, where appropriate,
when we are instituting proceedings at its own expense against such
parties in the name of the Covered Person. The Covered Person
further agrees that the Company will have a lien to the extent of
benefits provided, Such lien may be filed with the person whose act
caused the Injury, the person’s agent or a court having jurisdiction
in the matter.
CLAIM PROCEDURE
In the event of financial loss from a covered Injury or Sickness,
the student should:
- Secure a Company claim form from the claims administrator
named below, from the school or on the
web. No claim will be processed
without a completed form.
- Follow the instructions on the claim form.
- Bills must be received by the claims administrator within 90
days of service.
PLAN ADMINISTERED BY:
P.O. Box 727
Short Hills, NJ 07078-0727
All questions should be directed to Bollinger at
1-866-267-0092
PREFERRED PROVIDER NETWORK:
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 the
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 CKY505B.
| Policy Form SH1000GPM(Rev.2000).KY |
917343 |
