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 and scholars admitted to the University are eligible.
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.
Eligible students and scholars 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 dependents 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. 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. J1 Vistor 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
non-medical 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 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.
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;
- 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 twelve 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:
- twelve 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 twelve 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
J1 Exchange Visitors and students
enrolling their eligible dependents must complete an Enrollment
Form with the required premium made payable to:
Bollinger, Inc.
P.O. Box 398
Short Hills, NJ 07078
ENROLLMENT INSTRUCTIONS
Read this Brochure.
Complete the Enrollment Form. Be
sure to indicate the term of coverage, and if you are purchasing
dependent coverage.
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.
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.
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:
CLA808D |
|
