MEMBER ELIGIBILITY

ELIGIBILITY

1. 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

2. You must be residing outside your home countryfor the purpose of pursuing international educational activities; and

3. You must not have obtained residency status in your host country; and

4. 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.

CERTIFICATE EFFECTIVE & TERMINATION DATES

CERTIFICATE EFFECTIVE DATE

Insurance hereunder is effective on the later of:

1. The moment we receive an application and correct premium if the application and payment is made online or by fax;

2. 12:01am U.S. Eastern Time on the date we receive an application and correct premium if the application and payment is made by mail; The moment you depart from your home country;or

3. 12:01am U.S. Eastern Time on the date requested on the application.

CERTIFICATE TERMINATION DATE

Insurance hereunder terminates on the earlier of:

1. 11:59pm U.S. Eastern Time on the last day of the period for which premium has been paid;

2. 11:59pm U.S. Eastern Time on the date requested on the application;

3. 12:01am U.S. Eastern Time on the date you no longer meet eligibility requirements; or

4. 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).

DEFINITIONS

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.

Acute Onset of Pre-existing Condition means a sudden and unexpected outbreak or recurrence of a preexisting condition(s) which occurs spontaneously and without advance warning either in the form of physicianrecommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the certificate effective date. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A pre-existing condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset.

This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the certificate effective date.

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, up to 364 days, after which a newcertificate period will begin.

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 nonacute care for the comatose, semi-comatose, paralyzed or mentally incompetent patients.

Cyber means the use or operations, as a means for inflicting harm, of any computer, computer software program, malicious code, computer virus or process or any other electronic system.

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.

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 supervision 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, or a patient held for observation in a hospital for at least 12 hours.

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.

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 diseases including but not limited to syphilis, gonorrhea, chlamydiosis, trichomoniasis, genital herpes, and Human Papillomavirus (HPV).

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 localanesthesia.

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 lesser of the following:

1. One and a half times (150%) of the charges payable under the United States Medicare program, for claims incurred outside the PPO network within the U.S., or

2. 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 customarycharges 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

Plan Details

Overall Maximum Limit

$500,000

Maximum per Injury / Illness

$250,000

Deductibles (except Emergency Room)

$45 per injury or illness within the Preferred Provider Organization

(PPO) network 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. only)

$350 for treatment received in an emergency room

Coinsurance - Claims Incurred in U.S.

 

In-Network Payment

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.

Out-Of-Network Payment

Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount

Coinsurance - Claims Incurred outside

U.S.

We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.

Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise.

Benefit

Limit

Hospital Room and Board

Average semi-private room rate, including nursing services

Intensive Care Unit

Up to the overall maximum limit

Local Ambulance

Up to $500 per injury or illness, when covered illness or injury results in hospitalization as inpatient. - not subject to coinsurance

Outpatient Treatment

Up to the overall maximum limit

Outpatient Prescription Drugs

50% of actual charges - not subject to deductible or coinsurance

Outpatient Physical Therapy & Chiropractic

Care

Up to $50 per visit per day - not subject to coinsurance

Must be ordered in advance by a physician and not obtained at a student health center

Intercollegiate, Interscholastic,

Intramural, or Club Sports

Up to $3,000 maximum per injury or illness, medical expenses only

Mental Health Disorders (Includes drug

abuse and alcohol abuse)

Treatment must not be provided at a student health center.

Outpatient: Maximum of 30 visits.

Inpatient: Maximum of 30 days.

Maternity Care for a Covered Pregnancy

Up to $5,000.

Nursery Care of Newborn

Up to $250 - not subject to coinsurance

Therapeutic Termination of Pregnancy

Up to $500 - not subject to coinsurance

Dental Treatment due to Accident

Up to $250 maximum per tooth; $500 maximum per certificate

period - not subject to coinsurance

Emergency Dental (Acute Onset of Pain)

Up to $100 - not subject to deductible or coinsurance

Acute Onset of Pre-existing Condition

(Excludes chronic and congenital

conditions)

Up to $25,000 lifetime maximum for eligible medical expenses

Terrorism

Up to $50,000 lifetime maximum, eligible medical expenses only

All Other Eligible Medical Expenses

Up to the overall maximum limit

Emergency Travel Benefits

Limit

Emergency Medical Evacuation

Up to $250,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Repatriation of Remains

Up to $25,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Emergency Reunion

Up to $1,000, subject to a maximum of 15 days - not subject to deductible, coinsurance, or overall maximum limit

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, up to 364 days, after which a new certificate period will begin.

Coinsurance means your payment of eligible expenses at the percentage specified in the Schedule of Benefits and Limits.

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.

Usual, Reasonable and Customary means the lesser of the following:

1. One and a half times (150%) of the charges payable under the United States Medicare program, for claims incurred outside the PPO network within the U.S., or

2. 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.

BENEFIT PERIOD & HOME COUNTRY COVERAGE

BENEFIT PERIOD

While the certificate is in effect, the benefit period does not apply. Upon termination of the certificate, in accordance with this provision, we will pay eligible medical expenses for up to 60 days beginning on the first day of diagnosis or treatment of a covered injury or illness while you are outside your home country and while this certificate is in effect. The benefit period applies only to eligible medical expenses related to a condition for which you are hospitalized as an inpatient on the termination date of the certificate. In the event you begin a benefit period while the certificate is in effect, and the certificate terminates because you return to your home country, we will pay eligible medical expenses which are incurred in your home country during the benefit period. Home country coverage applies only to eligible medical expenses for which you are hospitalized as an inpatient on the termination date of the certificate.

INCIDENTAL HOME COUNTRY COVERAGE

For every three-month period during which you are covered, you are eligible for up to a maximum of 15 days of coverage in your home country for eligible medical expenses. Any benefit accrued under a single three-month period does not accumulate to another period. Failure to continue your international trip or your return to your home country for the sole purpose of obtaining treatment for an illness or injury that began while traveling shall void any home country coverage provided under the terms of this agreement.

For all non-U.S. citizens electing coverage “Excluding the U.S.” and for all U.S. citizens or residents, no coverage is provided within the U.S., except for U.S. citizens or residents during an eligible incidental home country visit or an eligible benefit period.

Except for a benefit period, coverage provided under this Master Policy is for a maximum duration of 364 days. Any extension is based upon the eligibility rules in force and is solely at our discretion. Notwithstanding the foregoing, coverage under all plans shall terminate on the date we, at our sole option, elect to cancel all members of the same sex, age, class or geographic location, provided we give no less than 30 days advance written notice by mail to your last known address.

MEDICAL & REPATRIATION EXPENSES

Subject to the limits set forth in the Schedule of Benefits and Limits, and subject to the conditions and restrictions contained in this provision, we will pay the following expenses incurred while this insurance is in effect.

MEDICAL EXPENSES

YOU ARE COVERED:

1. Charges made by a hospital for:

a. Daily room and board and nursing services not to exceed the average semi-private room rate; and

b. Daily room and board and nursing services in Intensive Care Unit; and

c. Use of operating, treatment or recovery room; and

d. Services and supplies which are routinely provided by the hospital to persons for use while

inpatients; and

e. Emergency treatment of an injury or illness, even if hospital confinement is not required. However, charges for use of the emergency room itself within the U.S. will be subject to deductible as provided under the Schedule of Benefits and Limits.

2. Surgery at an outpatient surgical facility, including services and supplies.

3. Charges made by a physician for professional services, including surgery. Charges for an assistant surgeon are covered up to 20% of the usual, reasonable and customary charge of the primary surgeon, but standby availability will not be deemed to be a professional service and therefore is not covered hereunder.

4. Dressings, sutures, casts or other supplies which are medically necessary and administered by or under the supervision of a physician, but excluding nebulizers, oxygen tanks, diabetic supplies, supplies that are available over the counter or without prescriptions, and support or brace appliances.

5. Diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, intelligence, behavioral and educational testing are not included).

6. Artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the replacement or repair thereof.

7. Reconstructive surgery when the surgery is directly related to surgery which is covered hereunder.

8. For radiation therapy or treatment and chemotherapy.

9. Hemodialysis and the charges by the hospital for processing and administration of blood or blood components but not the cost of the actual blood or blood components.

10. Oxygen and other gasses and their administration by or under the supervision of a physician.

11. Anesthetics and their administration by a physician.

12. Drugs which require prescription by a physician for treatment of a covered injury or illness, but excluding drugs: prescribed for the treatment of diabetes, replacement of lost, stolen, damaged, expired or otherwise compromised drugs.

13. Care in a licensed extended care facility upon direct transfer from an acute care hospital.

14. Home nursing care in bed by a qualified licensed professional, provided by a home health care agency upon direct transfer from an acute care hospital and only in lieu of medically necessary inpatient hospitalization.

15. Emergency local ambulance transport necessarily incurred in connection with injury or illness resulting in inpatient hospitalization.

16. Emergency dental treatment and dental surgery necessary to restore or replace sound natural teeth lost or damaged in an accident which was covered under this insurance.

17. Emergency dental treatment necessary to resolve acute onset of pain, provided treatment is obtained within 24 hours of the acute onset of pain.

18. Medically necessary rental of durable medical equipment (consisting of a standard basic hospital bed and or a standard basic wheelchair) up to the purchase prices.

19. Outpatient physical therapy if prescribed by a physician for treatment of a covered injury or illness.

20. Routine and medically necessary care of newborns as provided in the Schedule of Benefits, provided that the delivery of the newborn is covered hereunder.

21. Pre-natal care, delivery of newborn, and post-natal care related to a covered pregnancy which began after the effective date of coverage.

22. For treatment of mental health disorders including drug abuse and alcohol abuse.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

EMERGENCY MEDICAL EVACUATION

YOU ARE COVERED:

1. Emergency air transportation to a suitable airport nearest to the hospital where you will receive treatment; and

2. Emergency ground transportation necessarily preceding emergency air transportation; and from the destination airport to the hospital where you will receive treatment.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The evacuation is recommended by the attending physician who certifies that it is medically necessary and that transportation by any other method would result in the loss of your life or limb; and

2. The evacuation is agreed upon by you or your relative; and

3. Travel arrangements, excluding Emergency Local Ambulance, are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. The illness or injury giving rise to the expense is not covered under this insurance; or

2. Medically necessary treatment, services and supplies can be provided locally; or

3. If transportation by any other method would not result in the loss of your life or limb; or

4. The condition giving rise to the Emergency Medical Evacuation did not occur spontaneously and without advance warning, either in the form of physician recommendation or symptoms which would have caused a prudent person to seek medical attention prior to the onset of the emergency; or

5. Expenses are directly or indirectly from anything in the General Exclusions.

We will provide Emergency Medical Evacuation only to the nearest hospital that is qualified to provide the medically necessary treatment, services and supplies to prevent your loss of life or limb.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

Notwithstanding the foregoing, and if you are visiting the U.S., we will pay for expenses to return you to your home country if the attending physician and our medical consultant agree that transfer to the home country is more appropriate than transfer to the nearest qualified hospital.

REPATRIATION OF REMAINS

YOU ARE COVERED:

1. Air or ground transportation of bodily remains or ashes to the airport or ground transportation terminal nearest your principal residence; and

2. Reasonable costs of preparation of the remains necessary for transportation.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The illness or injury giving rise to the expense are covered under this insurance; and

2. Travel arrangements are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

We are held harmless and shall not be held liable for loss of or any damage or other impairment to bodily remains incurred during the repatriation process or otherwise.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

EMERGENCY REUNION

YOU ARE COVERED:

1. The cost of an economy round-trip air or ground transportation ticket for one relative for transportation to the terminal serving the area where you are hospitalized or are to be hospitalized following Emergency Medical Evacuation; and

2. Reasonable expenses for lodging and meals for the relative, which are incurred in the area where you are hospitalized for a period not to exceed 15 days.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You have a covered Emergency Medical Evacuation; or

2. You are hospitalized as an inpatient for at least five days due to a life-threatening covered condition. Emergency Reunion benefits not related to an Emergency Medical Evacuation will be paid only following the end of the minimum five day inpatient stay.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

SPORTS AND ACTIVITIES

A. INTERCOLLEGIATE, INTERSCHOLASTIC, INTRAMURAL, OR CLUB SPORTS

YOU ARE COVERED:

1. Subject to the limit set forth in the Schedule of Benefits and Limits, you are covered for a new injury or illness sustained while covered under this policy and taking part in sanctioned intercollegiate, interscholastic, intramural, or club sports.

YOU ARE NOT COVERED IF:

1. The sports or athletics are not sanctioned by your school; or

2. The activity is performed in a professional capacity or for any wage, reward, or profit; or

3. The injury or illness is sustained while you are not actively covered hereunder; or

4. Expenses arise directly or indirectly from anything mentioned in the General Exclusions.

B. LEISURE, RECREATIONAL, ENTERTAINMENT, OR FITNESS SPORTS AND ACTIVITIES

YOU ARE COVERED:

1. Subject to the overall maximum limit, you are covered for injury or illness sustained while taking part in sports and activities, unless it is excluded below.

You must ensure the activity is adequately supervised and that appropriate safety equipment (such as protective headwear, life jackets etc.) are worn at all times.

YOU ARE NOT COVERED IF:

1. The sports or athletics involve regular or scheduled practice and/or games; or

2. The activity is performed in a professional capacity or for any wage, reward, or profit; or

3. Expenses arise directly or indirectly from anything mentioned in the General Exclusions; or

4. Any of the excluded items listed below:

Aviation (except when traveling solely as a passenger in a commercial aircraft)

  • Base Jumping
  • BMX freestyle
  • Bungee Jumping
  • Free-Diving
  • Hang-Gliding
  • Jet Skiing

Mountaineering where a reasonably prudent person would use ropes or guides or at elevations of 4,500 meters or higher

  • Parachuting
  • Racing by any Animal, Motorized Vehicle, or BMX
  • Skateboarding
  • Sky Diving
  • Sky Surfing
  • Snow Skiing and Snowboarding, except recreational downhill and/or cross-country snow skiing or snowboarding (no cover provided while skiing away from prepared and marked in-bound territories and/or against the advice of the local ski school or local authoritative body)
  • Spelunking
  • Sub Aqua Pursuits involving
  • underwater breathing apparatus
  • unless accompanied by a certified
  • instructor at depths less than 10
  • meters, or PADI/NAUI certified
  • Surfing
  • Whitewater Kayaking and Rafting

TERRORISM

YOU ARE COVERED:

1. Eligible Medical Expenses for treatment of injuries and illnesses resulting from an Act of Terrorism, up to the limit set forth in the Schedule of Benefits and Limits, provided all of the following conditions are met.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The injury or illness does not result from the use of any biological, chemical, cyber, radioactive or nuclear

agent, material, device or weapon;

2. You have no direct or indirect involvement in the Act of Terrorism;

3. The Act of Terrorism is not in a country or location where the U.S. Department of State has issued a level 3 or level 4 travel advisory that has been in effect within the 6 months immediately prior to your date of arrival; and

4. You have not failed to depart a country or location within 10 days following the date a level 3 or level 4 travel advisory for that country or location is issued by the United States government.

YOU ARE NOT COVERED IF:

1. Loss, damage, cost or expense directly or indirectly caused by, resulting from or in connection with any ofthe following regardless of any other cause or event contributing concurrently or in any other sequence to the loss, damage, cost or expense:

a. War, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power;

b. The use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon; however, this exclusion shall not apply where you are exposed to nuclear radioactive and/or radioactive material for the purpose of medical treatment;

c. Any Act of Terrorism, not specifically covered above;

d. Coverage for loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to (a), (b) or (c) above; and

e. Expenses arise directly or indirectly from anything mentioned in the General Exclusions.

For the purpose of this insurance, an “Act of Terrorism” means an act, including but not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.

If we allege that by reason of this exclusion, any loss, damage, cost or expense is not covered by this insurance, the burden of proving the contrary shall be upon you.

In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.

Cyber means the use or operations, as a means for inflicting harm, of any computer, computer software program, malicious code, computer virus or process or any other electronic system.

GENERAL EXCLUSIONS

Excluded Conditions, Treatments (includes Diagnoses, Tests, and Examinations), Services, Supplies, Acts, Omissions, and/or Events:

1. Pre-existing Conditions during the first six (6) months of coverage under StudentSecure Elite and Select, during the first twelve (12) months under StudentSecure Budget, and are excluded throughout coverage under StudentSecure Smart, except charges resulting directly from an Acute Onset of Pre-existing Condition, an Emergency Medical Evacuation, or Repatriation of Remains.

 2. Congenital illnesses.

3. Immunizations, routine physical exams, and other diagnostic labs, x-rays, and procedures for screening or preventative purposes, except under StudentSecure Elite as provided for under the Vaccination benefit.

 4. 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.

 5. Mental health disorders if treatment is obtained at a student health center.

 6. Physical therapy if treatment is obtained at a student health center.

 7. 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.

8. Routine pre-natal care, pregnancy, child birth, post-natal care, and nursery care of a newborn, unless directly related to a covered pregnancy.

9. Elective termination of pregnancy.

10. Promotion or prevention of conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.

11. All sexually transmitted diseases and conditions.

12. HIV, AIDS, or ARC, and all diseases caused by and/or related to HIV.

13. Organ or tissue transplants or related services.

14.  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.

15. Voluntarily using any drug, narcotic or controlled substance, unless as prescribed by a physician.

 16. 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. 17. Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.

18. 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.

19. Orthoptics and visual eye training.

20. 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.

21. Hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed.

22. Acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, hypertrophic and atrophic conditions of skin, nevus.

23. Sleep apnea or other sleep disorders.

24. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.

25. Psychometric, intelligence, competency, behavioral and educational testing.

26. 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.

27. Cosmetic or aesthetic reasons, except for reconstructive surgery when such surgery is directly related to and follows a surgery which was covered hereunder.

28. Modifications of the physical body intended to improve the psychological, mental or emotional well-being, including but not limited to sex-change surgery.

 29. Obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass surgery.

30. Exercise programs, whether or not prescribed or recommended by a physician.

31. Incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).

 32. 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.

33. Investigational, experimental or for research purposes.

34. Complications or consequences of a treatment or condition not covered hereunder.

35. Incurred outside your certificate period.

36. Submitted to us for payment more than 60 days after the last day of the certificate period.

37. Exceeding usual, reasonable and customary.

38. Not medically necessary.

 39. Not administered by or ordered by a physician.

40. Provided by a relative, family member or any person who ordinarily resides with you.

 41. Provided at no cost to you.

42. Telephone consultations or failure to keep a scheduled appointment.

43. When departure from the home country is to obtain treatment in the destination country/countries.

44. Travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Repatriation of Remains, and Emergency Reunion sections of this insurance.

45. Payable under any government system, including the Australian Medicare system.

46. War, military action or while on duty as a member of a police or military force unit.

 47. Not included as Eligible Expenses as described herein.

 

 

Acute onset of pre-existing condition (excludes chronic and congenital conditions)

$25,000 lifetime maximum for eligible expenses

ACUTE ONSET OF PRE-EXISTING CONDITION

Acute Onset of Pre-existing Condition means a sudden and unexpected outbreak or recurrence of a preexisting condition(s) which occurs spontaneously and without advance warning either in the form of physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the certificate effective date. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A pre-existing condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset.

This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the certificate effective date.

YOU ARE COVERED:

1. Charges for a sudden and unexpected outbreak or recurrence of a pre-existing condition(s) which:

a. Occurs spontaneously and without advance warning either in the form of physician recommendations or symptoms; and

b. Is of short duration; and

c. Is rapidly progressive; and

d. Requires urgent care

YOU ARE NOT COVERED unless you fulfill the following condition:

 1. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence

YOU ARE NOT COVERED IF:

1. The Acute Onset of a Pre-existing Condition(s) occurs before the certificate effective date; or

2. The pre-existing condition is a chronic or congenital condition or that gradually becomes worse over time; or

3. The charges are for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the certificate effective date; or

 4. Expenses arise directly or indirectly from anything in the General Exclusions

Acute Onset of Pre-existing Condition (Excludes chronic and congenital conditions)

Up to $25,000 lifetime maximum for eligible medical expenses

PRE-EXISTING CONDITIONS EXCLUSION

Pre-existing Conditions during the first twelve (12) months of coverage, except charges resulting directly from an Acute Onset of Pre-existing Condition, an Emergency Medical Evacuation, or Repatriation of Remains, subject to the limits set forth in the Schedule of Benefits and Limits.

PRE-EXISTING MEDICAL CONDITIONS

Charges resulting directly or indirectly from any pre-existing conditions are excluded from this

insurance during the first twelve (12) months of coverage, except charges resulting directly from an

Acute Onset of Pre-existing Condition, an Emergency Medical Evacuation, or Repatriation of

Remains, subject to the limits set forth in the Schedule of Benefits and Limits

.Pre-existing Condition means 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

U.S. PREFERRED PROVIDER ORGANIZATION (PPO)

This insurance policy offers the option of a PPO network for medical treatment received in the United States. If you choose to seek treatment from a PPO provider, billed charges for eligible expenses may be reduced and we will remit payment directly to the provider. Additionally, we will apply the innetwork coinsurance applicable to the expenses.

You may review a listing of hospitals, physicians and other medical service providers included in the PPO Network for the area where you will be receiving treatment by accessing the Internet website for Tokio Marine HCC - MIS Group: www.hccmis.com. For assistance locating a provider, contact us at 1-800-605-2282

U.S. PREFERRED PROVIDER ORGANIZATION (PPO) REQUIREMENTS

Nothing contained in this insurance restricts or interferes with your right to select the hospital, physician or other medical service provider of your choice. Nothing contained in this insurance restricts or interferes with the relationship between you and the hospital, physician or other providers with respect to treatment or care of any condition, nor your right to receive, at your own expense, services and/or supplies that are not covered under this insurance.

To comply with the United States Preferred Provider Organization requirements, you must receive medical treatment from PPO providers while in the United States. If you choose to seek treatment from a PPO provider, we will apply the coinsurance applicable to the expenses.

You may review a listing of hospitals, physicians and other medical service providers included in the PPO Network for the area where you will be receiving treatment by accessing the Internet website for Tokio Marine HCC - MIS Group: www.hccmis.com. For assistance locating a provider, contact us at 1-800-605-2282

 

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 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 must be made online with payment by credit card.

CANCELLATION

We hope you are happy with the cover this policy provides. However, if after reading it, this insurance does not meet with your requirements, please notify us of your wish to cancel and we will refund your premium.

Premiums will be refunded in full if cancellation request is received prior to the certificate effective date.

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

CLAIMS

This insurance policy has in it a Claims Procedure which tells you what steps you must take to file a claim, and explains our obligations to you. Beginning on the last day of your certificate period, you shall have 60 days to provide us proof of claim

APPEALS AND COMPLAINTS

This insurance policy has in it an Appeals and Complaints Procedure which tells you what steps you can take if you wish to make an appeal or complaint.

CLAIM PROCEDURES

You must submit a claim for any expenses to be paid by us. This includes treatment or services for which you expect the medical provider will bill us directly. No payments will be made by us without you first submitting a claim

Notice of claim, Claimant’s Statement and Authorization, and proof of claim must be mailed to:

Tokio Marine HCC - MIS Group

 P.O. Box 2005

Farmington Hills, MI 48333-2005

USA

PROOF OF CLAIM

When we receive notice of a claim, we will provide you with forms for filing proof of claim. The following is considered to be proof of claim:

1. A completed and signed Claimant’s Statement and Authorization form, together with any/all required attachments;

2. Original itemized bills from physicians, hospitals and other medical providers; and

3. Original receipts for any expenses which have already been paid by you or on your behalf.

Beginning on the last day of your certificate period, you shall have 60 days to provide us proof of claim (unless medical services were rendered after the certificate termination date, in which case you shall have 60 days from the date the claim is incurred). Subsequent to receipt of proof of claim, we may, at our sole discretion, request and require additional information, including but not limited to medical records, necessary to confirm the validity of any claim prior to payment thereof.

CLAIMS COOPERATION

You shall provide assistance and co-operate with us or our representatives in obtaining any other records we or they feel necessary to evaluate the incident or claim. Following notification of a claim, you shall provide, when asked, all authorizations necessary to obtain your medical records. If you do not co-operate with us and/or our investigation of the claim, we shall not be liable to pay any claim

ACCESS TO ADDITIONAL MATERIALS

You shall provide us, or our designated representatives, all information, documentation, medical information that we or they may reasonably require during the term of this policy, or until all claims have been resolved, whichever is later.

OTHER INSURANCE

We shall not pay any claim if there is other insurance which would, or would but for the existence of this insurance, pay such claim. This insurance will apply with respect to expenses in excess of the amount paid or payable under such other insurance. We shall not pay any claim in respect to care, treatment, services or supplies furnished by any program or agency funded by any government.

ARBITRATION

 Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration by the American Arbitration Association in accordance with its Consumer Arbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Where any dispute is by this provision referred to arbitration, the making of an award shall be a condition precedent to any right of action against us.

APPEAL AND COMPLAINTS PROCEDURE

APPEALING A CLAIM

In the event we deny all or part of a claim under this insurance, you may file a written appeal with us. The written appeal must include sufficient information to identify the claim under appeal and must specify the reason(s) for the appeal with supporting documentation, if applicable.

Please provide your written appeal online or by postal mail at the following:

http://service.hccmis.com/ or Tokio Marine HCC - MIS Group

 P.O. Box 2005

Farmington Hills, MI 48333-2005

USA

When we receive the appeal, we will review the claim and a written response will be sent to you. After you receive our response to the appeal, you may initiate a second appeal. With our receipt of the second appeal, medical and/or claims personnel who were not involved in the original claim determination or the initial appeal will review the claim. A final determination will be made and a letter will be sent to you.

Please note that appealing a claim is not a requirement to following the complaints procedure detailed below.

COMPLAINTS PROCEDURE

We are dedicated to providing a high-quality service and want to ensure that it is maintained at all times. If you feel that we or another party connected with this policy have not offered a first class service please contact us and we will do our best to resolve the problem.

Please provide your written complaint online or by postal mail at the following:

 http://service.hccmis.com/ or Tokio Marine HCC - MIS Group

P.O. Box 2005

Farmington Hills, MI 48333-2005

USA

For both appeals and complaints, you will be contacted within 3 (three) business days to inform you of what action is being taken. We will try to resolve the problem and give you an answer within four weeks. If it will take longer than four weeks we will tell you when you can expect an answer. If you have not been given an answer within 8 (eight) weeks we will tell you how you can take your complaint to the Financial Ombudsman Service for review. This complaints procedure does not affect any legal right you have to take action. Once you have received your final response from us, and if you are still not satisfied you can contact the Financial Ombudsman Service:

 Financial Ombudsman Service

Exchange Tower, Harbour Exchange Square, London, E14 9SR

Phone: +44 (0) 20 7964 0500

Email: complaint.info@financial-ombudsman.org.uk

If you have purchased your policy online or by other electronic means within the European Union (EU) you may also make your complaint via the EU’s online dispute resolution (ODR) platform. The website for the ODR platform is: http://ec.europa.eu/odr