Student Accidental Injury and Sickness Insurance - A Summary

Student

Injury and

Sickness

Insurance

Plan

Designed Especially

for the Students of

2012-2013

Policy # US041831

2016

Mandatory

Student

Accidental

Injury

Insurance

Plan

Designed For

The Students Of

Policy Number US268526

Group Number 15430019

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Our College is pleased to sponsor the following Student Accidental Injury Insurance Plan.

IMPORTANT! This coverage coordinates with any other insurance you may have.

As a full time student you will automatically be covered for accident insurance coverage under the basic plan at a cost of $3.75 per month. The basic accident insurance coverage is mandatory for all eligible students.

Students must actively attend classes for at least the first 31 days beginning with the first day for which coverage is purchased. The Company maintains the right to investigate student status and attendance records to verify that Policy eligibility requirements have been met. If the Company discovers that the Policy eligibility requirements have not been met, the Company’s only obligation is refund of premium. Eligibility requirements must be met each time a premium is paid to continue coverage.

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The coverage provided under the Policy ceases on the termination date. However, if a Covered Person has had a covered Injury for which they are hospital confined on the date his/her coverage terminates under the Policy, and for which benefits were paid or are payable before the termination date, covered medical expenses for such Injury will continue to be paid as long as the condition continues but not to exceed 60 days after the termination date, subject to the Lifetime policy benefit maximum.

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If an Injury to the Covered Person results in his incurring Eligible Expenses for any of the services in the SCHEDULE OF BENEFITS, we will pay the Eligible Expenses incurred, subject to the Deductible Amount and Coinsurance Percentage (if any), that are in excess of Expenses payable by any other Health Care Plan, regardless of any Coordination of Benefits provision contained in such Health Care Plan. The Covered Person must be under the care of a Physician when the Eligible Expenses are incurred. The Expense must be incurred solely for the treatment of a covered Injury:

1. While the person is insured under this Policy; or 2. During the Benefit Period stated on the

SCHEDULE OF BENEFITS.

The first Expense must be incurred within the time frame shown on the SCHEDULE OF BENEFITS.

The total of all medical benefits payable under this Policy is shown on the SCHEDULE OF BENEFITS: and

1. Subject to the specific maximums shown on the SCHEDULE OF BENEFITS; and

2. Subject to compliance with the requirement, set forth in the Limitations section of this Policy.

Medical Expense Benefits for each

_{Accidental Injury}

Benefits will be paid up to the Maximum Benefit for each service as scheduled below.

Mandatory Accident Plan Benefits:

Each Injury *URC/$1,500 100% of Maximum

Accidental Death &

Dismemberment Benefit $10,000 Maximum

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The terms shown below shall have the meaning given in this section whenever they appear in this Policy. Additional terms may be defined within the provision to which they apply.

“Accident” means a sudden, unforeseeable external

event which causes Injury to one or more Covered Persons.

“Benefit Period” means the period of time from the

date of Injury, as shown in the Schedule of Benefits.

“Covered Person” means a person eligible for

coverage as identified in the Application for whom proper premium payment has been made, and who is therefore insured under this Policy.

“Deductible” means the amount of Eligible Expenses

which must be paid by the Covered Person before benefits are payable under this Policy. It applies separately to each Covered Person.

“Eligible Expenses” means the Usual, Reasonable

and Customary charges for services or supplies which are incurred by the Covered Person for the Medically Necessary treatment of an Injury. Eligible Expenses must be incurred while this Policy is in force.

“He”, “his” and “him” includes “she”, “her” and “hers.”

“Hospital” means an institution which:

1. Is operated pursuant to law;

2. Is primarily and continuously engaged in providing medical care and treatment to sick and injured persons on an inpatient basis;

3. Is under the supervision of a staff of Physicians; 4. Provides 24 hour nursing service by or under

the supervision of a graduate registered nurse, (R.N.);

5. Has medical, diagnostic and treatment facilities, with major surgical facilities;

• On its premises; or

• Available to it on a prearranged basis; and 6. Charges for its services.

7. “Hospital” does not include: • A clinic or facility for:

• Convalescent, custodial, educational or nursing care;

• The aged, drug addicts or alcoholics; or

• Rehabilitation; or

• A military or veterans hospital or a hospital contracted for or operated by a national government or its agency unless:

• The services are rendered on an emergency basis; and

• A legal liability exists for the charges made to the individual for the services given in the absence of insurance.

“Hospital Stay” means a Medically Necessary overnight

confinement in a Hospital when room and board and general nursing care are provided for which a per diem charge is made by the Hospital.

“Injury” means bodily harm of which an Accident is

the proximate cause. All injuries to the same Covered Person sustained in one accident, including all related conditions and recurring symptoms of the Injuries will be considered one Injury.

“Medically Necessary” or “Medical Necessity” means

a treatment, service or supply that is: 1. required to treat an Injury;

2. prescribed or ordered by a Physician or furnished by a Hospital;

3. performed in a setting required by the condition; 4. consistent with the medical and surgical practices

prevailing in the area for treatment of the condition at the time rendered.

The purchasing or renting air conditioners; air purifiers, motorized transportation equipment, escalators or elevators in private homes, swimming pools or supplies for them; and general exercise equipment are not considered Medically Necessary.

The fact that a Physician may prescribe, authorize, or direct a service does not of itself make it Medically Necessary or covered by the Group Policy.

“Physician” means a person who is a Physician of

medicine, osteopathy, psychology or other legally qualified practitioner of a healing art that is required by law to be licensed and is acting within the scope of his/ her license under the laws in the state in which he/she practices and providing only those medical services which are within the scope of his/her license or certificate. It does not include an Insured, an Insured’s Spouse, Domestic Partner, son, daughter, father, mother, brother or sister or other relative;

“Supervised or Sponsored Activity” means a

Certificateholder or School authorized function: 1. In which the Covered Person participates; 2. Which is organized by or under its auspices; 3. Which is within the scope of customary activities

for such entity and is shown on the Schedule of Benefits.

“Usual, Reasonable and Customary” means the

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Benefits will not be paid for a Covered Person’s loss which:

1. Is proximately caused by the Covered Person’s own:

• Intentionally self inflicted Injury, suicide or any attempt thereat. (In Missouri this applies only while sane.);

• Voluntary self administration of any drug or chemical substance not prescribed by, and taken according to the directions of, a doctor (Accidental ingestion of a poisonous substance is not excluded.);

• Commission or attempt to commit a felony; • Participation in a riot or insurrection; • Injury caused by, contributed to or resulting

from the Covered Person’s use of alcohol, illegal drugs or medicines that are not taken in the dosage or for the purpose as prescribed by the Covered Person’s Physician.

2. Is proximately caused by:

• Declared or undeclared war or act of war; • Aviation, except as specifically provided

in this Policy;

• Sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, bacterial or viral infection, regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning. 3. Normal health checkups;

4. Dental care or treatment other than care of sound, natural teeth and gums required on account of Injury resulting from an Accident while the Covered Person is covered under this Policy, and rendered within 6 months of the Accident; 5. Services or treatment rendered by a Physician,

nurse or any other person who is:

• Employed or retained by the Policyholder; or

• Who is the Covered Person or a member of his immediate family;

6. Charges which:

• The Covered Person would not have to pay if he did not have insurance; or

• Are in excess of Usual, Reasonable and Customary charges.

7. An Injury that is caused by flight in:

• An aircraft, except as a fare paying passenger;

• A space craft or any craft designed for navigation above or beyond the earth’s atmosphere; or

• An ultra light, hang gliding, parachuting or bungi cord jumping;

8. Travel in or upon: • A snowmobile;

• Any two or three wheeled motor vehicle; • Any off road motorized vehicle not requiring

licensing as a motor vehicle;

9. Any Accident where the Covered Person is the operator of a motor vehicle and does not possess a current and valid motor vehicle operator’s license;

10. That part of medical expense payable by any automobile insurance policy without regard to fault. (Does not apply in any state where prohibited);

11. Injury that is :

• The result of the Covered Person being Intoxicated. (“Intoxicated” will have the meaning determined by the laws in the jurisdiction of the geographical area where the loss occurs); or

• Caused by any narcotic, drug, poison, gas or fumes voluntarily taken, administered, absorbed or inhaled, unless prescribed by a physician;

12. Any Sickness, except infection which occurs directly from an Accidental cut or wound or diagnostic tests or treatment, or ingestion of contaminated food,

13. An Injury resulting from participation in or practice for non School sponsored skiing, ice hockey, lacrosse, soccer or football;

14. Expenses to the extent that they are paid or payable under other valid and collectible group insurance or medical prepayment plan;

15. Blood or Blood plasma, except for charges by a Hospital for the processing or administration of blood;

16. Elective treatment or surgery, health treatment, or examination where no Injury is involved; 17. Eyeglasses, contact lenses, hearing aids, braces,

appliances, or examinations or prescriptions therefore;

18. Treatment in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay;

19. Treatment of temporomandibular joint (TMJ) disorders involving the installation of crowns, pontics, bridges or abutments, or the installation, maintenance or removal of orthodontic or occlusal appliances or equilibration therapy; 20. Cosmetic surgery, except for reconstructive

surgery on a diseased or injured part of the body; 21. Any loss which is covered by state or federal

worker’s compensation, employers liability, occupational disease law, or similar laws; 22. The repair or replacement of existing artificial

limbs, orthopedic braces, or orthotic devices; 23. Rest cures or custodial care (Custodial care is

care that does not require the regular services of trained medical or health professionals and that is designed primarily to assist in activities of daily living. Custodial care includes, but is not limited to, help in walking, getting in and out of bed, bathing, dressing, preparation and feeding of special diets, and supervision of medications which are ordinarily self-administered.

24. The repair or replacement of existing dentures, partial dentures, braces or fixed or removable bridges;

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Benefit Period shown in the Schedule of Benefits; 26. Orthopedic appliances which are used mainly

to protect an Injury so that a covered student can take part in interscholastic or intercollegiate sports;

27. Services and supplies furnished by the Policyholder’s infirmary, its employees, or doctors who work for the Policyholder’s;

28. Hernia of any kind; or any bacterial infection that was not caused by an Accidental cut or wound; 29. Prescription medicines unless specifically

provided for under this Policy.

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In the event of Injury, the student should:

1. Obtain a claim form from the Human Resource Office or at www.summitamerica-ins.com. Please submit one claim form for each Injury. Mail the completed claim form, all medical bills and copies of your other insurance carrier’s Explanation of Benefits Statements to the address below.

2. File claim within 20 days of Injury. Bills should be received by the Company within 90 days of service. Bills submitted after one year will not be considered for payment except in the absence of legal capacity.

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Submit All Claims, Claims Inquiries, and Eligibility Questions to:

SUMMIT AMERICA INSURANCE SERVICES

PO BOX 25936

Overland Park, KS 66225

www.summitamerica-ins.com

Call Toll Free (877) 246-6997

Or e-mail claims related questions to:

claims@summitamerica-ins.com

Plans are underwritten by the United

States Fire Insurance Company. Fairmont

Specialty and Crum & Forster are

registered trademarks of United States Fire

Insurance Company. The Crum & Forster

group of companies is rated A (Excellent)

by AM Best Company 2015.

Plan Arranged By:

Berkley Risk Services of Colorado

1873 South Bellaire Street, Suite 1010 Denver, CO 80222

(303) 357-2600

This is a brief description of coverage provided under group policy number, form number AH27261-CA, and is subject to the terms, conditions, limitations and exclusions

of the policy. Please see the policy and certificate for details. Coverage may vary or may not be available in all

states.

1/1/2016-12/31/2016 Identification Card

United States Fire Insurance Company

Eatontown, NJ 07724

______________________________________________ Insured (Name of Student)

Your Social Security Number is your ID Number.

If a premium has been paid, the Student whose name appears above has been insured under a Policy issued to:

CLAIM FILING INSTRUCTIONS

IMPORTANT: Coverage under this policy is EXCESS to all other insurance and claims must first be submitted to any other insurance. Mail all medical bills including the student's name, student ID number, address and name of the school the student attends to:

Summit America Insurance Services, PO BOX 25936, Overland Park, KS 66225

Electronic Payor # 37301