Study USA-HealthCare - PREFERRED300
- You must be under age 65; and
- a. A full-time student at a college or university (excluding online colleges and universities); or
- b. Within 31 days of being a full-time student at a college or university; or
- c. A student under age 19 enrolled in a secondary school; or
- d. A full-time scholar affiliated with an educational institution and performing work or research for at least 30 hours per week; and
- You must be residing outside your home country for the purpose of pursuing international educational activities; and
- You must not have obtained residency status in your host country; and
- If in the U.S., you must hold a valid education-related visa. A copy of the I-20 or DS2019 may be requested.
J-1 and F-1 visa holders: The full-time student/scholar status requirement is waived within the U.S. if you have a valid F-1 visa (including OPT) or a J-1 visa. Full-time status requirements remain in force for individuals holding M-1, or other category visas.
- You be the participant’s legally married spouse, or must be the participant’s unmarried child under age 19 years and chiefly dependent on the participant for support and maintenance; and
- You must accompany the participant abroad on a similar visa or passport while the participant engages in international educational activities; and
- You must be temporarily located outside the participant’s home country; and
- You must not have obtained residency status in the host country.
C. Special Conditions for Newborn or Adopted Children:
- Newborn or adopted children will be automatically covered as dependents for the first 31 days of life provided that the delivery is covered by this insurance or placement occurs while the participant’s coverage is in effect. If the delivery of the newborn is not covered under this insurance, the newborn is eligible for coverage beginning at 14 days of age.
- Newborn and adopted children must be enrolled within the first 31 days after birth for newborns or within 31 days of placement for adoptions. Enrollment requires written notification of the new dependent’s name, birth date, gender, and citizenship as well as payment of any additional premium due.
- If a newborn or adopted child is not enrolled by the 31st day following birth (for newborns) or placement (for adopted children), then coverage terminates on the 31st day.
Certificate Effective Date
Insurance hereunder is effective on the later of:
- The moment we receive application and correct premium if application and payment is made online or by fax; or
- 12:01am U.S .Eastern Time on the date we receive application and correct premium if application and payment is made by mail; or
- The moment you depart from your home country; or
- 12:01am U.S. Eastern Time on the date requested on the application.
Certificate Termination Date
Insurance hereunder terminates on the earlier of:
- 11:59pm U.S. Eastern Time on the last day of the period for which premium has been paid; or
- 11:59pm U.S. Eastern Time on the date requested on the application; or
- 12:01am U.S. Eastern Time on the date you no longer meet eligibility requirements; or
- The moment of arrival upon your return to your home country (unless you have started a benefit period or are eligible for home country coverage).
Accident means a sudden, unintentional and unexpected occurrence caused by external, visible means and resulting in physical injury to you. The cause or one of the causes of such accident is external to your own body and occurs beyond your control.
Acute Onset of Pain (Emergency Dental) means a sudden and unexpected occurrence of pain which occurs spontaneously and without advance warning, either in the form of physician or dentist recommendation or symptoms, including pain, which would have caused a prudent person to seek medical or dental attention prior to the onset of pain. Treatment must be obtained within 24 hours of the sudden and unexpected occurrence of pain.
Alcohol Abuse means any pattern of pathological use of alcohol that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.
Certificate means the document issued to you that provides evidence of benefits payable under the Master Policy.
Certificate Period means the period of time beginning on the date and time of the certificate effective date and ending on the date and time of the certificate termination date.
Coinsurance means your payment of eligible expenses at the percentage specified in the Schedule of Benefits and Limits.
Covered Pregnancy means a pregnancy which began after the effective date of coverage.
Custodial Care means that type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist you in performing the activities of daily living. Custodial care also includes non-acute care for the comatose, semi-comatose, paralyzed or mentally incompetent patients.
Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and Limits that you must pay per certificate period before eligible expenses are paid.
Dental Treatment means the care of teeth, gums or bones supporting the teeth, including dentures and preparation for dentures.
Dependent means the participant’s legally married spouse, or the participant’s unmarried child under age 19 years and chiefly dependent on the participant for support and maintenance, who is enrolled for coverage under this plan.
Drug Abuse means any pattern of pathological use of a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.
Durable Medical Equipment means a standard basic hospital bed and/or a standard basic wheelchair.
Educational or Rehabilitative Care means care for restoration (by education or training) of one’s ability to function in a normal or near normal manner following an illness or injury. This type of care includes, but is not limited to, vocational or occupational therapy and speech therapy.
Emergency means a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing your life or limb in danger if medical attention is not provided within 24 hours.
Extended Care Facility means an institution, or a distinct part of an institution, which is licensed as a hospital, extended care facility or rehabilitation facility by the state in which it operates; and is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a physician and the direct upervision of a registered nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a physician; and provides each patient with active treatment of an illness or injury. Extended care facility does not include a facility primarily for rest, the aged, substance abuse treatment, custodial care, nursing care or for care of mental health disorders or the mentally incompetent.
Full-time Scholar means an individual who is affiliated with an educational institution and is engaging in educational activities for at least 30 hours per week. These activities may include but not be limited to performing research in an area of specialty or teaching for a temporary period of time.
Full-time Student means a student at a college or university who is taking 10 credit hours (undergraduate students) or 6 credit hours (graduate students). Full-time student status for individuals enrolled at colleges or universities that do not use a credit hour system must provide documentation of full-time student status.
Home Country means, for U.S. Citizens, the United States of America, regardless of the location of your principal residence. For non-U.S. Citizens, home country is the country where you principally reside and receive regular mail.
Home Health Care Agency means a public or private agency or one of its subdivisions, which operates pursuant to law and is regularly engaged in providing home nursing care under the supervision of a registered nurse, and maintains a daily record on each patient, and provides each patient with a planned program of observation and treatment by a physician.
Home Nursing Care means services provided by a home health care agency and supervised by a registered nurse, which are directed toward the personal care of a patient, provided always that such care is provided in lieu of medically necessary inpatient care in a hospital.
Hospital means an institution which operates as a hospital pursuant to law, and is licensed by the state or country in which it operates; and operates primarily for the reception, care and treatment of sick or injured persons as inpatients; and provides 24-hour nursing service by registered nurses on duty or call; and has a staff of one or more physicians available at all times; and provides organized facilities and equipment for diagnosis and treatment of acute medical conditions on its premises; and is not primarily a rehabilitation facility, long-term care facility, extended care facility, nursing, rest, custodial care or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment.
Host Country means the country, other than the home country, in which you will engage in educational pursuits. For legal residents and citizens of the U.S., the host country must be outside the U.S., including the U.S. Virgin Islands, Puerto Rico, Guam, American Samoa, and the Northern Mariana Islands.
Illness means a sickness, disorder, illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. Illness does not include learning disabilities, attitudinal disorders or disciplinary problems.
Injury means an unexpected and unforeseen harm to the body caused by an accident that requires medical treatment.
Inpatient means a person who is an overnight resident patient of a hospital, using and being charged for room and board.
Intensive Care Unit means a cardiac care unit or other unit or area of a hospital that meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.
Investigational, Experimental or for Research Purposes means procedures, services or supplies that are by nature or composition, or are used or applied, in a way which deviates from generally accepted standards of current medical practice.
Medically Necessary means a service or supply which is necessary and appropriate for the diagnosis or treatment of an illness or injury based on generally accepted current medical practice as determined by us. A service or supply will not be considered medically necessary if is provided only as a convenience to you or the provider, and/or is not appropriate for your diagnosis or symptoms, and/or exceeds in scope, duration or intensity that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment of an illness or injury.
Member means an individual who is covered under this insurance.
Mental Health Disorder means a mental or emotional disease or disorder which generally denotes a disease of the brain with predominant behavioral symptoms; or a disease of the mind or personality, evidenced by abnormal behavior; or a disorder of conduct evidenced by socially deviant behavior. Mental health disorders include: psychosis, depression, schizophrenia, bipolar affective disorder, and those psychiatric illnesses listed in the current edition of the diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association.
Outpatient means a member who receives medically necessary treatment by a physician for injury or illness that does not require overnight stay in a hospital.
Participant means the full-time student or full-time scholar who is pursuing international educational activities outside of his/her home country and who is enrolled for coverage under this plan.
Physician means a Doctor of Medicine (MD), Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DDM), Doctor of Podiatry (DPM), Doctor of Osteopathy (DO), a licensed Physical Therapist or Physiotherapist, and a Doctor of Psychiatry (Psy.D) and a Doctor of Psychology (Ph.D.). Physician also includes a Certified Nurse Practitioner (CNP), Certified Registered Nurse Anesthetist (CRNA), Nurse Midwife or a Physician Assistant (PA) under the direction of a medical doctor. A physician must be currently licensed by the jurisdiction in which the services are provided, and the services must be within the scope of that license and covered under this Master Policy.
Relative means biological or step parent current spouse, biological or stepsiblings, or child or stepchild, age 18 or older.
Routine Physical Exam means and examination of the physical body by a physician for preventative or informative purposes only, and not for the diagnosis or treatment of any condition. Routine physical exam also includes diagnostic labs, x-rays, and other procedures for screening, preventative, or informative purposes.
Sexually Transmitted Diseases means syphilis, gonorrhea, lymphogranuloma venereum, chancroid, granuloma inguinale, chlamydiosis, trichomoniasis, genital candidiasis, genital herpes, Pelvic Inflammatory Disease (PID), Human Papillomavirus (HPV), mycoplasma genitalium, and viral hepatitis.
Student Health Center means a medical facility of an educational institution that provides basic health services for students for a minimum of 10 hours per week during the school semester. Basic services must include staffing by a licensed medical provider (MD, CNP, or RN) for the purpose of assessment and treatment of minor illnesses and injuries and/or referral to another medical provider.
Substance Abuse means alcohol, drug or chemical abuse, overuse or dependency.
Surgery or Surgical Procedure means an invasive diagnostic procedure, or the treatment of illness or injury by manual or instrumental operations performed by a physician while the patient is under general or local anesthesia.
Therapeutic Termination of Pregnancy means willful termination of pregnancy determined to be medically necessary for the wellbeing of the mother.
Usual, Reasonable and Customary means the most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. What is defined as usual, reasonable and customary charges will be determined by us. In determining whether a charge is usual, reasonable and customary, we may consider one or more of the following factors: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the severity or nature of the illness or injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; such other factors we, in the reasonable exercise of discretion, determine are appropriate.
You/Your means each insured person named in the certificate.
We/Us/Our means Tokio Marine HCC Medical Insurance Services Group.
Schedule of Benefits and Limits
Except as specifically indicated otherwise, all benefits are subject to deductible, coinsurance, and are per certificate period.
|Overall Maximum Limit||$300,000
(Excludes Emergency Medical Evacuation, Accidental Death and Dismemberment, Repatriation of Remains, and Emergency Reunion)
|Maximum per Injury / Illness||$300,000|
|Deductibles (except Emergency Room)||$45 per injury or illness within the Preferred Provider Organization (PPO) or student health center; otherwise $90 per injury or Illness.
If treatment received outside of U.S., $45 per illness or injury.
|Emergency Room Deductible –Claims incurred in U.S.||$250 for treatment received in an emergency room unless admitted as inpatient.|
|Coinsurance – Claims incurred in U.S.||Within the PPO, we will pay 80% of the next $25,000 of eligible expenses after the deductible, then 100% to the overall maximum limit.
Outside the PPO, we will pay 70% of the next $25,000 of eligible expenses after the deductible, then 100% to the overall maximum limit.
|Coinsurance – Claims incurred outside U.S.||We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.|
|Subject to deductible, coinsurance, and per certificate period unless specifically indicated otherwise|
|Hospital Room and Board||Average semi-private room rate, including nursing services|
|Intensive Care Unit||Usual, reasonable and customary charges|
|Local Ambulance||$350 per injury or illness, when covered illness or injury results in hospitalization as inpatient.|
|Outpatient Treatment||Usual, reasonable and customary charges|
|Outpatient Prescription Drugs||$10 copay for generic drugs
$20 copay for brand name
|Mental Health Disorders (includes drug abuse and alcohol abuse)||Outpatient: $50 maximum per day, $500 maximum.
Inpatient: Usual, reasonable and customary charges up to $10,000.
Treatment must not be provided at a student health center.
|Maternity Care for a Covered Pregnancy||We will pay 80% of eligible expenses up to the overall maximum or 70% outside the PPO.|
|Nursery Care of Newborn||$750|
|Therapeutic Termination of Pregnancy||$500|
|Physical Therapy and Chiropractic Care||$50 per visit per day
Must be ordered in advance by a physician and not obtained at a student health center
|Dental Treatment due to Accident||$1,000 maximum per certificate period|
|Wellness||100% of one routine physical exam per member|
|Intercollegiate, Interscholastic, Intramural, or Club Sports||$5,000 maximum per injury or illness, medical expenses only|
|Terrorism||$50,000 lifetime maximum, eligible medical expenses only.|
|All Other Eligible Medical Expenses||Usual, reasonable and customary charges|
|Not Subject to Deductible or Coinsurance|
|Dental Treatment to alleviate pain||$100|
|Emergency Medical Evacuation||$500,000 lifetime maximum|
|Repatriation of Remains||$25,000 lifetime maximum|
|Emergency Reunion||$2,500, subject to a maximum of 15 days|
|Accidental Death & Dismemberment||Lifetime Maximum - $25,000
Death - $25,000
Loss of 2 Limbs - $25,000
Loss of 1 Limb - $12,500
Charges for the following conditions, treatments (including diagnoses, tests, and examinations), services, supplies, acts, omissions, and/or events are excluded from coverage hereunder:
- Congenital illnesses.
- Immunizations and other diagnostic labs, x-rays, and procedures for screening or preventative purposes.
- Dental treatment and treatment of the temporomandibular joint, except for emergency dental treatment necessary to replace sound natural teeth lost or damaged in an accident covered hereunder or for the emergency relief of acute onset of pain.
- Mental health disorders if treatment is obtained at a student health center.
- Physical therapy if treatment is obtained at a student health center.
- Chiropractic treatment, unless ordered in advance by a physician for medically necessary treatment related to a covered injury or illness, and not obtained at a student health center.
- Routine pre-natal care, pregnancy, child birth, post-natal care, and nursery care of a newborn, unless directly related to a covered pregnancy.
- Elective termination of pregnancy.
- Promotion or prevention of conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
- Venereal disease, including all sexually transmitted diseases and conditions.
- HIV, AIDS, or ARC, and all diseases caused by and/or related to HIV.
- Organ or tissue transplants or related services.
- Self-inflicted injury or illness and/or suicide or attempted suicide whether sane or insane.
- Injury sustained that is due wholly or partially to the effects of intoxication or drugs other than drugs taken in accordance with treatment prescribed by a physician and except drugs prescribed for the treatment of substance abuse.
- Voluntarily using any drug, narcotic or controlled substance, unless as prescribed by a physician.
- Charges resulting from or occurring during the commission of a violation of law, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
- Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
- Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations.
- Orthoptics and visual eye training.
- Orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or toenails.
- Hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed.
- Acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, hypertrophic and atrophic conditions of skin, nevus.
- Sleep apnea or other sleep disorders.
- Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.
- Psychometric, intelligence, competency, behavioral and educational testing.
- While confined primarily to receive custodial care, educational or rehabilitative care, or any medical treatment in any establishment for the care of the aged, except rehabilitative care received upon direct transfer from an acute care hospital.
- Cosmetic or aesthetic reasons, except for reconstructive surgery when such surgery is directly related to and follows a surgery which was covered hereunder.
- Modifications of the physical body intended to improve the psychological, mental or emotional well-being, including but not limited to sex-change surgery.
- Obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass surgery.
- Exercise programs, whether or not prescribed or recommended by a physician.
- Incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
- Charges resulting from a disease outbreak in a country or location for which the U.S. Centers for Disease Control and Prevention (CDC) has issued a Level 3 Travel Warning if a) the warning has been in effect within the 6 months immediately prior to your date of arrival, or b) within 10 days following the date the warning is issued you have failed to depart the country or location.
- Investigational, experimental or for research purposes.
- Complications or consequences of a treatment or condition not covered hereunder.
- Incurred outside your certificate period.
- Submitted to us for payment more than 60 days after the last day of the certificate period.
- Exceeding usual, reasonable and customary.
- Not medically necessary.
- Not administered by or ordered by a physician.
- Provided by a relative, family member or any person who ordinarily resides with you.
- Provided at no cost to you.
- Telephone consultations or failure to keep a scheduled appointment.
- When departure from the home country is to obtain treatment in the destination country/countries.
- Travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Repatriation of Remains, and Emergency Reunion sections of this insurance.
- Payable under any government system, including the Australian Medicare system.
- War, military action or while on duty as a member of a police or military force unit.
- Not included as Eligible Expenses as described herein.
Any (1) condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the 12 months immediately preceding the Certificate Effective Date; (2) condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 12 months immediately preceding the Certificate Effective Date; (3) injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 12 months immediately preceding the Certificate Effective Date.
To comply with the United States Preferred Provider Organization requirements, the Member must receive medical treatment from PPO providers while in the United States. If the Member chooses to comply with the PPO requirements, and the expenses are incurred in a PPO provider, Underwriters will waive the Coinsurance applicable to the expenses.Members may review a listing of Hospitals, Physicians and other medical service providers included in the PPO Network for the area where the Member will be receiving treatment by accessing the Internet website for HCC Medical Insurance Services.
After your initial purchase, you may extend your coverage up to a maximum of 364 days from the initial effective date. You may renew your coverage as long as you continue to meet the eligibility requirements. Renewal may be completed within the last 6 months of a 12-month certificate period. Deductible and coinsurance must be re-satisfied as of each renewal date. After four years of continuous coverage or any break in coverage, a new plan must be purchased. A new application is required and you must re-satisfy your deductible, coinsurance, pre-existing condition provisions, and all other benefit limits. Extensions and renewals can be made online with payment by credit card or by calling us at (800) 937-1387
Premiums may be refunded after the certificate effective date subject to the following provisions: 1. A $25 cancellation fee will apply for administrative costs incurred by us; and 2. Only premium for unused whole-months, if paying in monthly installments, or unused days, if paid in full, of the plan will be refunded; and 3. You cannot have filed any claims to be eligible for premium refund; and 4. No refund of premium shall be granted after 60 days.
When Underwriters receive notice of claim, they will provide the Member with forms for filing Proof of Claim. The following is considered to be Proof of Claim:
- A completed and signed Claimant’s Statement and Authorization form, together with any/all required attachments; and
- Original itemized bills from Physicians, Hospitals and other medical providers; and
- Original receipts for any expenses which have already been paid by or on behalf of the Member.
The Member shall have 60 days beginning on the last day of the Certificate Period to submit Proof of Claim to Underwriters, unless medical services were rendered after the Certificate Termination Date, in which case the Member shall have 60 days from the date the claim is incurred to submit Proof of Claim to Underwriters.
Time Limit – In the event Underwriters deny all or part of a claim under this insurance, the Member shall have 90 days from the date notice
Appeal Procedure – Within 60 days of Underwriters’ receipt of the appeal, Underwriters’ will review the claim. A written response will be forwarded to the Member.