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How to Read Your Explanation of Benefits

Any questions about the Policy should be directed to:
Bollinger, Inc.
P.O. Box 727
Short Hills, NJ 07078
866-267-0092 (Claims/Coverage)
800-526-1379 (Other Questions)

ELIGIBILITY

All domestic students, age 65 and younger, taking 7 or more credit hours are eligible to enroll in the Plan.
Students must be physically and actively attending classes on campus to enroll in this Plan. On-line students or distance learning students taking home study, correspondence, or television courses are not eligible to enroll in this plan. Coverage will become invalid for students who leave school within 31 days of their effective date of coverage. The Plan Administrator should be notified at that time by the student. Students who enroll in the Plan may secure family coverage. Dependents must enroll in the Plan when the student first enrolls in the Plan, and must enroll for the same coverage as the student. Eligible dependents are the spouse residing with the Insured Student, and unmarried children and grandchildren under twenty-four years of age who are not self-supporting and reside with the Insured Student.

EFFECTIVE AND EXPIRATION DATES

Your coverage becomes effective on the later of the Policy Effective Date (08-15-07); the first day of the
term for which the proper premium has been paid; or 12:01 A.M. following the date the envelope containing the completed Enrollment Form and proper premium for the period of coverage is postmarked by the US Postal Service. All coverage expires on 08-14-08 or when payment is due and unpaid. Newborn children
will be covered at birth until 31 days old or until well enough to be discharged from the hospital, if the Plan Administrator is notified within 30 days of birth and receives proper premium.

MANDATED BENEFITS

The Plan will pay benefits for the following mandated benefits and any other applicable mandate in accordance with Louisiana insurance laws: Pap Smears/Cervical Cancer Screening; Mammography; Prostate Cancer Screening; Mastectomy Reconstruction; Bone Density; Off-Label Drugs; Inherited Metabolic Disease; Diabetes Equipment, Supplies and Outpatient Self-Management Training and Education; Transliteration Services; Cancer Clinical Trials; Well-Child Care/Immunizations; Cleft Palate; Dental Anesthesia; and ADD/Hyperactivity.

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 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 the Policy and the prior coverage.

EXCLUSIONS

Benefits will not be paid under the Policy and any attached Rider for any expenses which result from:

1. Services that are provided normally without charge by the University's health center, infirmary or hospital; or by any person employed by the University;

2. Eyeglasses, radial keratotomy, contact lenses, hearing aids or prescriptions or examinations except as required for repair caused by a covered Injury;

3. Declared or undeclared war, riot, civil disorder, civil commotion or acts of terrorism;

4. Injury or Sickness for which benefits are payable under any Worker's Compensation or Occupational Disease Law;

5. Expenses resulting from a motor vehicle accident for which benefits are payable from other valid insurance;

6. Elective Surgery or Elective Treatment;

7. Elective abortion;

8. Injury resulting from the playing, practice, participating, or conditioning in any intercollegiate or interscholastic 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;

9. 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 instructions for University credit;

10. Expenses incurred as the result of dental treatment, except as specifically provided for treatment resulting from Injury to natural teeth;

11. Suicide, attempted suicide or intentionally self-inflicted Injury while sane or insane;

12. Organ transplants;

13. Committing or attempting to commit an assault or felony; or fighting, except in self defense; and

14. Injury 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 or the purpose prescribed by the Insured Person's physician.

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 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 the Policy.

Covered medical expenses resulting from a Preexisting Condition will not be covered unless:

1. six 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 the Policy and the University's prior policies for six continuous 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.

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 Insured Person is covered by other valid and collectible insurance, all benefits payable by such insurance will be determined before benefits will be paid by the Policy. The Policy is second payor to any other insurance having primary status or no coordination or non-duplication of benefits provision.

If the Insured 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 the 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.

DEFINITIONS

ELECTIVE SURGERY means any surgery or treatment that is not Medically Necessary which includes but is not limited to: circumcision; tubal ligation; vasectomy; breast reduction; breast implants; sexual reassignment surgery; removal of non-malignant warts and moles; orthognathic surgery, including mandibular retrognathia; and submucous resection and/or other surgical correction for deviated nasal septum.

Elective surgery does not mean a Cosmetic Procedure required to correct an Injury for which benefits are otherwise payable under the Policy.

INJURY means bodily Injury caused by an accident. The accident must occur while the Insured 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, or disease which 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 a similar condition will be considered the same Sickness.

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.

CLAIM PROCEDURES

Secure a claim form from the Student Health Service; from the Plan Administrator or online, fill in the necessary information, attach all itemized doctor and hospital bills and send to:
Bollinger, Inc.; P.O. Box 727, Short Hills, NJ 07078.

Notice of claim must be provided to the address above within 30 days after the Injury or commencement of Sickness. Proof of loss must be submitted to the address above within 90 days from the date if due to Injury or Sickness. To check the status of your filed claim, please call the Plan Administrator from 7:00 A.M. to 4:00 P.M.
(Central Time), Monday through Friday. The telephone number is 866-267-0092.

ENROLLMENT INSTRUCTIONS

1. Read and Retain this Brochure.

2. Complete the Enrollment Form. Be sure to indicate the term of coverage, and if you are purchasing dependent coverage.

3. Enclose your check made payable to Bollinger, Inc. for the full premium. There is no reduction in premium for late enrollees. Only premium amounts indicated on the Enrollment Form will be accepted. Timely payment of subsequent premiums is the student’s responsibility. However, a billing will be sent to the address listed on the Enrollment Form.

4. Return the Enrollment Form and payment to
   Bolinger, Inc., P.O. Box 727, Short Hills, NJ
   07078.

101 JFK PARKWAY
SHORT HILLS, NJ 07078
(866) 267-0092 (Claims/Coverage)
(800) 526-1379 (Other Questions)
 

PREFERRED PROVIDER NETWORK:

Please keep this Brochure as a general summary of insurance. The Master Policy on file at the University contains all of the Policy 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.

 

Policy Form: SH1000GPM

Policy: CLA508D