SABA University School of Medicine, Accident and Sickness Insurance (“Clinical Rotation” Students and Dependents)
Underwritten By: ACE American Insurance Company (Herein referred to as “We”, “Our”, or “Us”)
Eligibility: All domestic and international students who are studying in the United States and participating in the Clinical Medicine portion of the Medical Degree Program are eligible to enroll in the Student Accident and Sickness Insurance Plan. Eligibility is extended to students while taking sabbatical to study for the United States Medical Licensing Exam. Students enrolled in the Student Accident and Sickness Insurance Plan may also enroll their dependent(s) as defined. “Dependent” means: (a) the Insured Student’s spouse residing with the Insured Student; or (b) the Insured Student’s unmarried children under the age of nineteen years; or (c) a child born to an Insured Student while this Plan is in force will be covered by this Plan. Coverage for such newborn children will consist of coverage for accident or sickness, including necessary care or treatment of congenital defects, birth abnormalities, or premature birth. Such coverage will start from the moment of birth, if the Insured Student is already insured for dependent coverage when the child is born. If the Insured Student does not have dependent coverage when the child is born, We cover the newborn child, for dependent benefits, for the first 31 days from the moment of birth. An adopted child will be covered on the same basis as a newborn child from the date of placement by a licensed placement agency, in the Insured Student’s home, for purposes of adoption. A foster child will be covered from the date of the filing of a petition to adopt, if the child has been residing in the Insured Student’s home as a foster child from when the Insured Student has received foster care payments. To continue the child’s dependent benefits past the first 31 days, the Insured Student must complete and return the Dependent Enrollment Form with payment within 31 days of the child’s birth.
Period of Coverage: Insurance becomes effective at 12:01 A.M. at the University’s address on the latest of: 1) the effective date of the Policy, September 1, 2007; or 2) the date the person becomes eligible; or 3) the date the enrollment form and full premium are received by the Plan Administrator or Us. Insurance will terminate at 12:01 A.M. Standard Time on the earliest of the following dates: 1) September 1, 2008; or 2) the last day of the period through which the premium is paid; or 3) the date the eligibility requirements are not met; or 4) the date the Covered Person enters full-time active duty service in any Armed Forces. A refund of premium will be made when We receive proof of active duty.
Definitions: You, Your or Yours means the Insured Student. Covered Person means any Insured Student and Dependent who enrolls for coverage and for whom the required premium is paid. Injury means accidental bodily harm sustained by a Covered Person that results directly and independently from all other causes from a Covered Accident. The Injury must be caused solely through violent and accidental means. All injuries sustained by one person in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered a single Injury. Sickness means an illness, disease or condition of the Covered Person that causes a loss for which a Covered Person incurs medical expenses while covered under the Policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness. Pregnancy is included in the definition of Sickness. Doctor means a licensed health care provider acting within the scope of his or her license and rendering care or treatment to a Covered Person that is appropriate for the conditions and locality. It will not include a Covered Person or a member of the Covered Person’s immediate family member or household. Covered Expenses means expenses actually incurred by or on behalf of a Covered Person for treatment, services and supplies covered by the Policy. Coverage under the Policy must remain continuously in force from the date of the Accident or Sickness until the date treatment, services or supplies are received for them to be a Covered Expense. A Covered Expense is deemed to be incurred on the date such treatment, service or supply, that gave rise to the expense or the charge, was rendered or obtained. Medical Emergency means a condition caused by an Injury or Sickness that manifests itself by symptoms of sufficient severity that a prudent lay person possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of the person in serious jeopardy. Usual and Customary Charge(s) means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided. Medically Necessary means a treatment, service or supply that is: 1) required to treat an Injury or Sickness; 2) prescribed or ordered by a Doctor or furnished by a Hospital; 3) performed in the least costly setting required by the Covered Person’s condition; and 4) consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered. A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may at Our discretion, consider the cost of the alternative to be the Covered Expense.
Medical Expense Benefits: We will pay, after a $500.00 deductible per Injury or Sickness, 80% of the Usual and Customary Charge incurred for the first $20,000; then 100% of the Usual and Customary Charge incurred up to an Aggregate Maximum of $500,000 per covered Injury or Sickness. A deductible of $500.00 will apply per Emergency Room visit per covered Injury or Sickness. The Emergency Room deductible will be waived if the Covered Person is admitted to the Hospital. The deductible amounts consist of covered expenses that would otherwise be paid by the policy. The deductibles are the Covered Person’s responsibility. The Covered Expenses shall in no event include any amount which is in excess of usual and customary charges for similar treatment, services or supplies in the locality where the expense is incurred. In no event shall the Company’s liability for each covered person exceed $500,000 per covered Injury or Sickness.
Covered Expense:
To be considered a Covered Expense under this Plan, it must: a) have been incurred as the result of, and within 52 weeks of, a Covered Sickness or Injury during the Period of Coverage b) not be excluded by provisions of this Plan; and c) be specifically included in the following list of expenses:
1. Expenses made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional services with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the hospital’s average charge for semiprivate room and board accommodation or the necessary intensive care (ICU) room and board for the ICU.
2. Expenses made for miscellaneous hospital services and supplies while hospital confined or day surgery on an outpatient basis for: anesthesia, operating room, laboratory tests, and x-rays.
3. Expenses made for diagnosis, treatment and surgery by a doctor.
4. Expenses for Assistant Surgeon when Medically Necessary.
5. Anesthesiologist Expenses for pre-operative screening and administration of anesthesia during a surgical procedure whether on an inpatient or outpatient basis.
6. Expenses for x-ray services, laboratory tests, medical services and supplies, (includes blood and blood transfusions; oxygen and its administration) and durable, medical equipment, both inpatient and outpatient.
7. Expenses incurred for in-hospital doctor visits limited to one visit per day.
8. Expenses for Doctor Non-Surgical Treatment/Examination Expenses (excluding medicines) including the Doctor’s initial visit, each Medically Necessary follow-up visit and consultation visits when referred by the attending Doctor.
9. Medical Emergency Care (room and supplies) Expenses: incurred within 72 hours of an Accident and including the attending Doctor’s charges, X-rays, laboratory procedures, use of the emergency room and supplies.
10. Expenses for Medically Necessary physiotherapy or chiropractic outpatient treatments, We will pay the Usual and Customary Charge incurred for such treatments. Physiotherapy/Chiropractic Care means heat treatment or diathermy, Ultrasonic, microtherm, manipulation, adjustment, massage therapy and acupuncture. Services must be prescribed by a licensed Doctor and must include a prescription for a stated number of treatments. The referring Doctor must issue a new prescription following medical evaluation of the Covered Person’s condition, for any additional treatment required for the condition.
11. Expenses for prescription drugs including dressings, drugs and medicines prescribed by a doctor:
12. Expenses for accident related dental expenses for treatment resulting from Injury to sound natural teeth.
Other Covered Expenses:
Ambulance Expense: If a Covered Person requires the use of a community or hospital ambulance for a Medical Emergency, We will pay 100% of the Usual and Customary Charge incurred up to a maximum of $250.00 per Injury or Sickness.
Voluntary Abortion Expense: If as a result of pregnancy having its inception during the term insured, a Covered Person has a voluntary abortion, We will pay 100% of the Usual and Customary Charge incurred up to a maximum of $350.00. Expenses for the voluntary abortion must be incurred while the Plan is in force as to the Covered Person.
Mental and Nervous Benefits
Inpatient Expense: If a Covered Person requires treatment for mental and nervous disorders while hospital confined, We will pay the Usual and Customary Charge incurred for any such confinement on the same basis as any other Sickness, but payment will not be made for more than 60 days per policy year.
Outpatient Expense: If a Covered Person is not hospital confined, We will pay 80% of the Usual and Customary Charge incurred up to a maximum of $500.00 per policy year.
Alcohol and Substance Abuse Benefits
Inpatient Expense: If due to alcoholism, alcohol abuse, substance abuse, or substance dependency, a Covered Person requires treatment during a confinement in a hospital, Detoxification Facility, or residential alcohol and substance treatment program for persons remanded to such programs for drunk driving, We will pay the Usual and Customary Charge for any such confinement on the same basis as any other Sickness, but payment will not be made for more than 30 days in any one calendar year.
Outpatient Expense: If due to alcoholism, alcohol abuse, or substance dependency, a Covered Person requires outpatient treatment services in a hospital or Detoxification Facility, We will pay 80% of the Usual and Customary Charge for outpatient services, up to a maximum of $500.00 per policy year.
Mammography Examination Expense: If a Covered Person requires a mammography exam, We will pay 100% of the Usual and Customary Charge for the following: (a) a baseline mammogram for women between the ages of thirty-five and forty years of age and older; or (b) a mammogram on an annual basis for women forty years of age and older.
Cytologic Screening Expense: If a Covered Person eighteen years of age or older requires a cytologic screening (pap smear), We will pay 100% of the Usual and Customary Charge for a cytological screening once a year, or more fre¬quently if recommended by a Doctor. Such benefits will include the examination, laboratory fee, and the Doctor’s interpretation of the laboratory results.
Maternity Expense: If a Covered Person or spouse is pregnant, We will pay for any Expense incurred which are medically necessary including expenses for prenatal care, childbirth and post partum care (including well baby care on the same basis as any other Sickness. (Elective abortion and elective cesarean section are not included as covered expenses.) Expenses for childbirth include hospital inpatient care of not less than 48 hours following a vaginal delivery or not less than 96 hours following a cesarean section, unless the attending physician, in consultation with the mother makes a decision for an earlier discharge from the hospital. Covered Expenses will also include expenses for post-delivery care such as but not limited to: home visits, parent education, assistance and training in breast or bottle feeding and the performance of any necessary and appropriate clinical tests. However, the first home visit must be conducted by a registered nurse, certified nurse midwife or physician and any future home visits determined to be necessary must be provided by a licensed health care provider.
Preventive and Primary Care Expense for Children: We will pay 80% of the Expense actually incurred for preventive and primary care expenses actually incurred. These are for services rendered to a dependent child of a Covered Person from the date of birth through the attainment of six years of age. These services are limited to the following: physical examination, history, measurements, sensory screening, neuropsychiatric evaluation and development screening, and assessment at the following intervals: six times during the child’s first year after birth, three times during the next year, annual until age six. Such services will also include hereditary and metabolic screening at birth, appropriate immunizations, and tuberculin tests, hematocrit, hemoglobin or other appropri¬ate blood tests, and urinalysis as recommended by the Doctor.
Hospice Care Treatment Expense: We pay for charges made by a licensed hospice for the Covered Expenses of a Covered Person with a life expectancy of six months or less. Services must be authorized by a duly licensed physician.
Early Intervention Services Expense: We will pay 80% of the Expense actually incurred up to a maximum of $3,200 per policy year and $9,600 over the total enrollment for Early Intervention Services. These services include occupational, physical, speech therapy; nursing care and psy¬chological counseling. Expenses are payable for a dependent child of an Insured Person from birth until their third birthday.
High Cost Outpatient Procedures Expense: If a Covered Person incurs expenses for specific outpatient procedures costing over $200, We will pay 80% of the Usual and Customary Charges incurred up to a maximum of $2,000 per covered Injury or Sickness. Specific outpatient procedures include, but are not limited to: CAT scan, magnetic resonance imaging and laser treatments. This benefit is payable in addition to any other benefit payable under this insurance program.
Off Label Use of Prescription Drugs Expense: We will pay 100% of the Usual and Customary Charge for expenses incurred for off label use of prescription drugs that have not been approved by the Federal Drug Administration for the treatment of cancer and HIV/AIDS.
Cardiac Rehabilitation Expense: If a Covered Person requires Cardiac Rehabilitation treatment in connection with documented cardiovascular disease. We will pay for such treatment on the same basis as any other Sickness. Such treatment shall include, but is not limited to, outpatient treatment which is to be initiated within 26 weeks after the diagnosis of such disease.
Infertility Expense: If a Covered Person incurs medically necessary expenses for diagnosis and treatment of Infertility, We will pay benefits on the same basis as any other Sickness. Covered Expenses include expense incurred for the following non-experimental infertility procedures: (1) Artificial Insemination; (2) In Vitro Fertilization and Embryo Placement; (3) Sperm, egg and/or inseminated egg procurement, processing and banking to the extent such costs are not covered by the donor’s insurer, if any; (4) Gamete Intra Fallopian Transfer; (5) Intracytoplasmic Sperm Injection for the treatment of male factor infertility; and (6) Zygote Intrafallopian Transfer. The term “Infertility” means the condition of a presumably healthy individual who is unable to con¬ceive or produce conception during a period of one year.
Home Health Care Expense: When, by reason of Injury or Sickness, a Covered Person incurs Expenses for covered home health care services. We will pay, after a $50.00 deductible, 80% of the Usual and Customary Charge on the same basis as any other Injury or Sickness for the Expenses incurred up to a maximum of 40 vis¬its within 12 months from the date of the first home health care visit. Four hours of home health care is considered one home care visit.
Non-prescription Enteral Formulas Expense: We will pay 100% of the Usual and Customary Charge up to $2,500.00 per policy year for benefits for non-prescription enteral formulas which are medically necessary for the treatment of mal absorption caused by Crohn’s Disease, ulcerative colitis, gastro esophageal reflux, gastroin¬testinal motility, chronic intestinal pseudo-obstruction, and inherited disease of amino acids and organic acids.
Bone Marrow Transplant for Treatment of Breast Cancer Expense: If a Covered Person has metastatic breast cancer, We will pay 80% of the Covered Expenses up to the Aggregate Maximum for the expense of a bone marrow transplant for the treatment of breast cancer.
Glucose Monitoring for Diabetic Treatment Expense: If a Covered Person has insulin depend¬ent diabetes, We will pay 80% of the Covered Expenses for blood glucose monitoring strips for home use for which a Doctor has written an order and are medically necessary for the treatment of insulin dependent diabetes.
Services Performed By Certified Registered Nurse Anesthetists and Nurse Practitioners Expense: We pay 100% of the Usual and Customary Charge for services by Nurse Practitioners and Certified Registered Nurse Anesthetists (CRNA) if the service performed is within the scope of the nurse practitioner’s authority to prac¬tice or the CRNA’s license and if the Plan currently provides benefits for identical services ren¬dered by a health care provider licensed in Massachusetts.
Special Medical Formulas Expense: Coverage will be provided for special medical formulas which are approved by the Commissioner of the Department of Health, prescribed by a Doctor, and are Medically Necessary expenses for treatment of phenylketronia, tyrosinemia, homo-cystinuria, maple syrup urine disease, propionic acidemia, or metylmolonic acidemia in infants and children or are Medically Necessary to protect the unborn child of pregnant women with phenylktonuria.
Reconstructive Breast Surgery Expense: If a Covered Person incurs an expense for recon¬structive surgery following a mastectomy, We will pay the 100% of the Usual and Customary Charges incurred for such expense.
Emergency Medical Evacuation Benefit: The Company will pay Emergency Medical Evacuation Benefits for 100% of Covered Expenses incurred for the medical evacuation of a Covered Person. Benefits are payable if the Covered Person: 1) suffers a Medical Emergency during the course of the Trip; 2) requires Emergency Medical Evacuation; and 3) is traveling outside of his or her Home Country.
Covered Expenses:
1. Medical Transport: expenses for transportation under medical supervision to a different hospital, treatment facility or to the Covered Person’s place of residence for Medically Necessary treatment in the event of the Covered Person’s Medical Emergency and upon the request of the Doctor designated by Our assistance provider in consultation with the local attending Doctor.
2. Dispatch of a Doctor or Specialist: the Doctor’s or specialist’s travel expenses and the medical services provided on location, if, based on the information available, a Covered Person’s condition cannot be adequately assessed to evaluate the need for transport or evacuation and a doctor or specialist is dispatched by Our service provider to the Covered Person’s location to make the assessment.
3. Return of Dependent Child(ren): expenses to return each Dependent child who is under age 18 to his or her principal residence if a) the Covered Person is age 18 or older; and b) the Covered Person is the only person traveling with the minor Dependent child(ren); and c) the Covered Person suffers a Medical Emergency and must be confined in a Hospital.
4. Escort Services: expenses for an Immediate Family Member or companion who is traveling with the Covered Person to join the Covered Person *during the Covered Person’s emergency medical evacuation to a different hospital, treatment facility or the Covered Person’s place of residence.
Benefits for these Covered Expenses will not be payable unless: 1) the Doctor ordering the Emergency Medical Evacuation certifies the severity of the Covered Person’s Medical Emergency requires an Emergency Medical Evacuation; 2) all transportation arrangements made for the Emergency Medical Evacuation are by the most direct and economical conveyance and route possible; 3) the charges incurred are Medically Necessary and do not exceed the Covered Expenses for similar transportation, treatment, services or supplies in the locality where the expense is incurred; and 4) do not include charges that would not have been made if there were no insurance. An Emergency Medical Evacuation of a covered person to their Home Country, terminates all benefits under this plan except Accidental Death and Dismemberment Benefits.
“Medical Emergency” means a condition caused by an Injury or Sickness that manifests itself by symptoms of sufficient severity that a prudent lay person possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of the person in serious jeopardy. “Trip” means travel by air, land, or sea from the Covered Person’s Home Country.
“Emergency Medical Evacuation” means: 1) the Covered Person’s immediate transportation from the place where he or she suffers Medical Emergency to the nearest Hospital or other medical facility where appropriate medical treatment can be obtained; or 2) the Covered Person’s transportation to his or her Home Country to obtain further medical treatment in a Hospital or other medical facility or to recover after suffering a Medical Emergency. An Emergency Medical Evacuation also includes medical treatment, medical services and medical supplies necessarily received in connection with such transportation.
Benefits will not be payable unless the Company authorizes in writing, or by an authorized electronic or telephonic means, all expenses in advance, and services are rendered by the assistance provider.
Repatriation of Remains: The Company will pay Repatriation Benefits of 100% of Covered Expenses for preparation and return of a Covered Person’s body to his or her home if he or she dies as a result of a Medical Emergency while traveling outside of his or her Home Country. Covered expenses include: 1) expenses for embalming or cremation; 2) the least costly coffin or receptacle adequate for transporting the remains; 3) transporting the remains; and 4) Escort Services: expenses for an Immediate Family Member or companion who is traveling with the Covered Person to join the Covered Person’s body during the repatriation to the Covered Person’s place of residence. All transportation arrangements must be made by the most direct and economical route and conveyance possible and may not exceed the Covered Expenses for similar transportation in the locality where the expense is incurred.
Benefits will not be payable unless We authorize in writing, or by an authorized electronic or telephonic means, all expenses in advance, and services are rendered by Our assistance provider.
Excess Coverage: We pay Covered Expenses: 1) after the Covered Person satisfies any Deductible; and 2) only when they are in excess of amounts paid by any other Health Care Plan.
We pay benefits without regard to any Coordination of Benefits provisions in any other Health Care Plan shall be excess of all other valid and collectible insurance.
