Dear Student:
The administration is making available to the students and their
dependents, a plan of Blanket Injury and Sickness Insurance
(hereinafter called the "Plan" or "Plan"). The coverage is designed
to provide benefits for medical expenses arising from an Injury or
Sickness including those which occur off campus and during interim
vacations.
Any questions about the policy should
be directed to
Bollinger, Inc.
P.O. Box 727
Short Hills, NJ 07078
866-267-0093 (Claims/Coverage)
800-526-1379 (Other Questions)
ELIGIBILITY
All non-immigrant international
students admitted to the University are eligible. They are
automatically enrolled in this plan at registration; and the premium
for Student Only coverage is included in their tuition billing.
Students must be physically and actively attending classes on campus
to enroll in the Plan. On-line students or distance learning
students taking home study, correspondence, or television courses
are not eligible to enroll in this Plan.
Eligible students who have other
comparable coverage must provide proof to the University
International Student Division within 4 weeks after the start of
Fall and Spring Semesters respectively or within 2 weeks after start
of Summer Term. If approved by the University, and if no claim has
been incurred, a premium refund will be made by the Plan
Administrator.
Eligible students who are insured by
this Plan may enroll their eligible dependents in the Plan.
Dependents must enroll in the plan when the student first enrolls in
the Plan, and must enroll for the same coverage as the student. The
insured student may also add dependents within 30 days of: marriage,
involuntary loss of other coverage, birth or adoption of child, or
the date the dependent enters the USA. Eligible dependents are any
of the following persons who reside with the insured student in the
USA: the Insured student’s spouse; and unmarried dependent children
and grandchildren who are not yet 24 years old (older if incapable
of self-support due to mental or physical incapacity).
EFFECTIVE AND EXPIRATION DATES
The Master Policy begins at 12:01 A.M.
on August 15, 2007
and ends at 12:01 A.M. on August 14, 2008. An eligible student’s
coverage conditionally begins at 12:01 A.M. on the
later of: the Master Policy effective date, or three days before
the start of the academic term at which the student is eligible
provided that the required premium is received and no
authorized refund occurs. International Student and dependent
coverage becomes effective on the later of: the Policy
Effective Date; 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 U.S. Postal Service. Coverage of students and dependents ends at
12:01 a.m.
on the earliest of the following dates: (a) the date premium
is due but not received; (b) the date of the student’s nonmedical
withdrawal from the University, if within 31 days
after the start of the academic term for which registered; or
(c) the Master Policy’s termination date.
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 received 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
ACCIDENTAL DEATH AND DISMEMBERMENT
Occurring within 100 days from date of
Injury pays in addition one of the following (the largest applicable
amount):
Accidental
Death...............................................................$2,500
Single Dismemberment/Loss of
Eye........................................$1,500
Double Dismemberment/Loss of Both
Eyes...............................$2,500
Thumb and Index Finger on either
hand..................................$750
EXCLUSIONS
Benefits will not be paid under the
Policy and any attached Rider for any 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;
Eyeglasses, radial keratotomy, contact
lenses, hearing aids or prescriptions or examinations except as
required for repair caused by a covered Injury;
Declared or undeclared war, riot,
civil disorder, civil commotion or acts of terrorism;
Injury or Sickness for which benefits
are payable under any Worker's Compensation or Occupational
Disease Law;
Expenses resulting from a motor
vehicle accident for which benefits are payable from other valid
insurance;
Elective Surgery or Elective
Treatment;
Elective abortion;
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;
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;
Expenses incurred as the result of
dental treatment, except as specifically provided for treatment
resulting from Injury to natural teeth;
Suicide, attempted suicide or
intentionally self-inflicted Injury while sane or insane;
Organ transplants;
Committing or attempting to commit an
assault or felony; or fighting, except in self defense;
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; and
Expenses incurred within the Covered
Person's home country or country of regular domicile other than the
United States.
PRE-EXISTING CONDITION LIMITATION
No benefits will be payable for the
Insured's Pre-existing 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 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 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
International Student Office, Student Health Service Office, 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
Proof of loss must be submitted to
the address above within 90 days from the date of Injury or
Sickness.
To check the status of your filed
claim, please call the Claims Office from 7:00 A.M. to 4:00 P.M.
(Central Time), Monday through Friday. The telephone number is
866-267-0092.
TO APPLY FOR COVERAGE
International (F1) students
enrolling their eligible dependents must complete and Enrollment
Form with the required premium made payable to: Bollinger, Inc.
Return the Enrollment Form and payment to:
Bollinger, Inc.
P.O. Box 398
Short Hills, NJ 07078
The above office is authorized to
accept and process your completed Enrollment Form. Do not send
it elsewhere. No refunds except as provided in the Master
Policy.
The above office is authorized to
accept and process your completed Enrollment Form. Do not send
it elsewhere. No refunds except as provided in the Master
Policy.
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:
CLA708D |
|
