Coverage is in effect 24 hours a day. For students enrolled during the Fall Semester, coverage will be in effect from either August 15, 2008 or the date of Premium Payment, whichever is later, until January 15, 2009. For students enrolled during the Spring Semester, coverage will be in effect from either January 15, 2009, or the date of Premium Payment, whichever is later, until August 15, 2009. The plan covers injuries sustained and sickness contracted and causing loss commencing during the coverage period. The policy expires August 15, 2009. (Please note that this policy cannot establish physician’s fees, and therefore, cannot guarantee that payments made by Monumental Life Insurance Company, hereafter referred to as the Company, will cover all physician and surgeon charges in full.)
ACCIDENT MEDICAL EXPENSE BENEFITS
Benefits are provided up to $3,000 for accidental injuries for which medical treatment by a physician, surgeon, dentist, registered nurse, hospital services, ambulance services, or x-rays are rendered. The initial treatment must be rendered within 90 days of the accident and benefits are limited to treatment rendered within 52 weeks of the date of accident. Specific benefit levels are as shown below:
Hospital Room and Board:
The expense actually incurred is allowed not to exceed the semi-private rate per day up to a maximum of $3,000.
Hospital Inpatient Miscellaneous Expense:
The expenses actually incurred are allowed not to exceed $3,000 as the result of any one Inury.
Surgical Expense:
The expense actually incurred is allowed not to exceed $100 times the unit value of the MDR allowance, or $2,500 in
total for all surgical operation(s) performed for any one Injury.
The expense actually incurred is allowed up to a maximum of $1,500 per covered accident.
Ambulance Expense:
The expense actually incurred is allowed not to exceed $300 for any one Injury.
Physician’s Expense:
Inpatient, limited to one visit per day, paid at the usual and customary rate, up to $45 per visit, to a $700 maximum. Outpatient, limited to one visit per day, paid at the usual and customary rate, up to $80 per visit, to an $800 maximum. Second surgical opinions will be covered up to the expense incurred subject to a maximum of $80.
Inpatient Graduate Nurse Expense:
The expense actually incurred is allowed subject to a maximum benefit of $50 per 24-hour period, or $800 maximum per Injury.
Outpatient Miscellaneous Expense:
The expense actually incurred is allowed subject to a maximum $1,500 as the result of any one Injury. Diagnostic procedures deemed necessary by a physician, or nurse practitioner, are covered on the same basis as any other medical condition, regardless of the results.
Dental Expense:
The Company will pay up to a maximum of $800 per injury for treatment to sound and natural teeth injured in a covered
accident.
Up to $60 per visit is allowed subject to a maximum of $300 for any one Injury.
Prescription Drug Expense:
The expense actually incurred is allowed up to a maximum of $300 per year (combined with Sickness).
Anesthesia Expense:
The expense actually incurred is allowed up to40% of the surgeon’s allowance.
Consultant’s Expense:
The expense actually incurred is allowed up to$80 per covered Injury.
ACCIDENTAL DEATH
$1,000 payable when injury results in the loss of life within 180 days of the accident.
ACCIDENTAL DISMEMBERMENT
$1,000 payable per the schedule as shown in the Master Policy.
SICKNESS MEDICAL EXPENSE BENEFITS
Sickness benefits will be paid up to $3,000 for medical expenses incurred within 52 weeks of the date of the first medical treatment subject to the following:
The expense actually incurred is allowed not to exceed the semi-private rate per day up to a maximum of
$3,000.
The expenses actually incurred are allowed not to exceed $3,000 as the result of any one Sickness
The expense actually incurred is allowed not to exceed $100 times the unit value of the MDR allowance, or $2,500 in total for all surgical operations performed for any one Sickness. (Note: Treatment of impacted wisdom teeth is covered on the same
basis as any other medical condition.)
Day Surgery Miscellaneous Expense:
The expense actually incurred is allowed up to a maximum of $1,500 per covered Sickness.
The expense actually incurred is allowed not to exceed $300 for any one Sickness.
Inpatient, limited to one visit per day, paid at the usual and customary rate, up to $45 per visit, to a $700 maximum. Outpatient, limited to one visit per day, paid at the usual and customary rate, up to $80 per visit, beginning with the second visit,
to an $800 maximum. If you use the college health center for your initial treatment, or if the student health center is closed or you are more than 50 miles from campus and see a physician, it will count as your first outpatient visit. Second surgical opinions will be covered up to the expense incurred subject to a maximum of $80.
The expense actually incurred is allowed subject to a maximum benefit of $50 per 24-hour period or $800 as the result of any one Sickness.
The expense actually incurred is allowed subject to a maximum $1,500 as the result of any one
Sickness. Diagnostic procedures deemed necessary by a physician, or nurse practitioner, are covered on the same basis as any other medical condition, regardless of the results. Additionally, the removal of nonmalignant growths will be covered, when deemed medically necessary
The expense actually incurred is allowed up to a maximum of $300 per year (combined with Accident).
The expense actually incurred is allowed up to 40% of the surgeon’s allowance.
Medical Consultation Expense:
The expense actually incurred is allowed up to $80 per covered Sickness.
WELLNESS BENEFIT
Benefits will be provided for expenses incurred in a health promotion program through health wellness examinations and counseling. Benefits shall include, but not be limited to, the following tests and services: (1) for all Insureds 16 years of age or older, annual tests to determine blood hemoglobin, blood pressure, blood glucose level, and blood cholesterol level or, alternatively, low-density lipoprotein (LDL) level and blood high-density lipoprotein (HDL) level; (2) for all Insureds 35 years of age or older, a glaucoma eye test every 5 years; (3) for all Insureds 40 years of age or older, an annual stool examination for presence of blood; (4) for all Insureds 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every 5 years (this examination is subject to a limit of $164.00 ); (5) for all female Insureds 16 years of age or older, a pap smear; (6) for all female Insureds 40 years of age or older, a mammogram examination; (7) for all adult Insureds, recommended immunizations; and (8) for all Insureds 20 years of age or older, an annual consultation with a health care provider to discuss lifestyle behaviors that promote health and well-being including, but not limited to, smoking control, nutrition and diet recommendations, exercise plans, lower back protection, weight control, immunization practices, breast self-examination, testicular self-examination, and seat belt usage in motor vehicles. Benefits payable under this section shall not exceed the following maximums for any one year: (1) $250.00 for Insureds between the ages of 20 and 39, inclusive; (2) $250.00 for all male Insureds ages 40 and over; (3) $391.00 for all female Insureds ages 40 and over; and (4) $250.00 for a left-sided colon examination
MANDATED BENEFITS
The plan will pay for the following mandated benefits and any other applicable mandate in accordance with New Jersey insurance laws: Alcoholism Treatment Benefit, Audiology and Speech language Pathology Benefit, Biological-based Mental illness Benefit, Blood Products and Blood Infusion Equipment Benefit, Certain Dental Services Benefit, Colorectal Cancer Screening Benefit, Diabetes Treatment Benefit, Home Health Care Benefit, Infertility Diagnosis and Treatment Benefit, Inherited Metabolic Diseases Benefit, Inpatient Coverage for Mastectomies and Reconstructive Breast Surgery Benefits, Mammography Benefit, Maternity Length of Stay Benefit, Pap Smear Benefit, Prostate Cancer Screening, Prosthetics and Orthotics Benefit, Treatment of Wilm’s Tumor Benefit, Wellness Health Examinations Benefit, Off-Label Drug Use Benefit, Prescription Female Contraceptive, and Dose-Intensive Chemotherapy.
EXTENSION OF MAXIMUM BENEFIT
For Both Accident and Sickness
After the Company pays $3,000 in basic benefits under either the accident or sickness provision of the policy for any one accident or sickness, this policy will pay 70% of the expenses incurred in excess of $3,000 up to but not exceeding $47,000 for physician’s services, hospital confinement, nursing services, X-Rays, operating room, emergency room, anesthesia, laboratory service, dressings, prescription medicines, casts, use of wheel chair, crutches, or ambulance for any one covered accident or sickness. Expenses must be incurred within two years from the date of accident or sickness.
EXCLUSIONS
The Policy does not cover:
1. Routine screenings or tests which are not Medically Necessary for the diagnosis or treatment of your condition or which are not specifically ordered by the admitting Physician, except as mandated by law and specifically provided under this Policy;
2. Eyeglasses, radial keratotomy, contact lenses, hearing aids or prescriptions or examinations except as required for repair caused by a covered Injury;
3. Expenses incurred as the result of dental treatment, except as specifically provided for treatment resulting from Injury to natural teeth;
4. War or any act of war, declared or undeclared: (1) while the Covered Person is serving in the armed forces of any country; (2) while the Covered Person is serving in any civilian non-combatant unit supporting or accompanying any armed forces of any country or international organization; or (3) while the Covered Person is not serving in any armed Force if the Injury or Sickness occurs outside the home area. A pro-rata premium will be refunded upon request for such period not covered;
5. Committing or attempting to commit an assault or felony; or fighting, except in self defense;
6. Injury resulting from the playing, practice, participating, or conditioning in any intercollegiate, contest or competition sponsored by the school, any professional or semi-professional sport, or Injury sustained while traveling to or from such sport, contest or competition as a participant;
7. 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;
8. Treatment provided in a government Hospital unless there is a legal obligation to pay such charges in the absence of other insurance;
9. Elective Surgery or Elective Treatment;
10. Well baby care other than Hospital nursery and related Physician’s charges for a newborn or care specifically provided under this Policy;
11. Injury or Sickness for which benefits are paid or payable under any Workers’ Compensation or Occupational Disease Law;
12. Organ transplants, except as specifically provided in this Policy;
13. Assistant surgeon fees;
14. Services and supplies not Medically Necessary for the diagnosis recommended by the attending Physician.
OPTIONAL MEDICAL EVACUATION BENEFIT
This optional benefit is subject to payment of the additional premium as specified on the enrollment card. Optional benefits may only be purchased at the time of initial enrollment in the plan and may not be added later. When recommended and approved by the attending Physician, arrangements will be made for the evacuation of the Insured to his natural country. Evacuation will be arranged and paid for by Medex. No additional benefits will be paid under Basic or Major Medical coverage for Medical Evacuation.
OPTIONAL REPATRIATION BENEFIT
This optional benefit is subject to payment of the additional premium as specified on the enrollment card. Optional benefits may only be purchased at the time of initial enrollment in the plan and may not be added later. If the Insured dies while Insured under the policy, arrangements will be made form preparing and transporting the remains of the deceased’s body to his home country. Repatriation will be arranged by
HANDLING CLAIMS
Written notice of claim must be given to the Insurer within 90 days after loss occurs or as soon as reasonably possible. A Company claim form is required for filing a claim. Mail to the address below all Medical and Hospital bills along with the patient’s name and insured student’s name, address, social security number and name of the college under which the student is insured. Claim forms are available at the Student Health Center.
Submit all claims to:
Short Hills, NJ 07078
THIS PLAN IS ADMINISTERED BY:
101 JFK PARKWAY
SHORT HILLS, NJ 07078
(866) 267-0092 (Claims/Coverage)
(800) 526-1379 (Other Questions)
PREFERRED PROVIDER NETWORK PROVIDED BY:
PLEASE KEEP THIS BROCHURE 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 in this Brochure. If any discrepancy exists between the Brochure and the Policy, the Master Policy will govern and control the payment of benefits.
Policy Form SHI5000GPM.NJ 6515395 6515395
