Student Health Advantage - Including USA
If an Insured Person is not eligible, this Certificate is void ab initio and all premium paid will be refunded. In order to be eligible and qualified for coverage under this insurance, a person must:
- be a Full-Time Student or Scholar, the Spouse of the Full-Time Student or Scholar, or a Dependent traveling with the Full-Time Student or Scholar, and residing outside their Home Country for the purpose of pursing international educational activities including, but not limited to college course work, research, or teaching for a temporary period of time; and
- at the time of the Effective Date, be physically residing in Host Country with the intent to reside there for at least thirty days; and
- complete and sign an Application as the Insured Person (or be listed thereon by proxy as an applicant and proposed Insured Person), and/or as the Insured Person’s spouse and/or Child; and
- pay the required Premium on or before the Effective Date of Coverage; and
- receive written acceptance of his/her Application or renewal from the Company; and
- be at least thirty one (31) days old but not yet sixty-five (65) years old; and
- not be Hospitalized or Disabled on the Initial Effective Date; and
- not be HIV+ on the Initial Effective Date.
|Maximum Limit||Student: $500,000; Dependent: $100,000|
|Maximum Limit per Illness or Injury||Student: $300,000; Dependent: $100,000|
|Deductible||$100 per illness or injury
Student health center: $5 copay per visit
|Coinsurance||Outside of the U.S.: Company pays 100%
In PPO network or student health center within the U.S.: Company pays 100%
Out of PPO network if within the U.S.: Company pays 80% of eligible expenses up to $5,000; then 100% thereafter
|Hospital Room and Board||Average semi-private room rate, including nursing service|
|Intensive Care||After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally|
|Emergency Room Injury||After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally|
|Emergency Room Illness resulting in Hospitalization||After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally|
|Emergency Room Illness without Inpatient Admission||After deductible is met, company pays 80% of expenses out-of- network (U.S.)
or 100% in-network (U.S.) and internationally; Subject to additional $250 deductible
|Mental or Nervous / Substance Abuse||Outpatient: $50 per day; $500 maximum limit; Inpatient: After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally up to $10,000 maximum limit; Student health center treatment: $0|
|Prescription Drugs||Inpatient: After deductible is met, company pays 80% of expenses out-of- network (U.S.)
or 100% in-network (U.S.) and internationally
Outpatient: 50% of actual charges
90 day dispensing maximum
(Medical order or treatment plan required)
|After deductible is met, company pays 80% of expenses out-of- network (U.S.)
or 100% in-network (U.S.) and internationally; limit one visit per day
|Local Ambulance||$350 per illness resulting in an inpatient hospitalization or injury|
|Dental||Non-emergency treatment at a dental provider due to an accident - $500 period of coverage limit per injury; Unexpected pain to sound, natural teeth - $350 period of coverage limit|
|Eligible Medical Expenses||After deductible is met, company pays 80% of expenses out-of- network (U.S.)
or 100% in-network (U.S.) and internationally
|Interfacility Ambulance Transfer
(For services rendered in the U.S.)
|Company pays 100%. Transfer must be a result of an inpatient hospital admission|
|Emergency Medical Evacuation||$500,000 maximum limit|
|Emergency Reunion||$50,000 maximum limit|
|Return of Mortal Remains||$50,000 maximum limit|
|Political Evacuation and Repatriation||$10,000 maximum limit|
|Intercollegiate/Interscholastic/Intramural or Club Sports||$5,000 period of coverage limit per illness or injury|
|Incidental Trip Coverage||Up to a cumulative 14 days (available for non-U.S. residents only)|
|Pre-existing Conditions||Charges excluded until after 12 months of continuous coverage|
|Terrorism||$50,000 maximum limit|
|AD&D||Student: $25,000 principal sum; Spouse: $10,000 principal sum; Dependent child: $5,000 principal sum
Accidental dismemberment percentage of principal sum
(Secondary to any other insurance)
|$10,000 combined maximum limit
Injury to third person: subject to a $100 per injury deductible
Damage to third person’s property: subject to a $100 per damage deductible
CORONAVIRUS (COVID-19/SARS-CoV-2) ENDORSEMENT
Attaching to and forming part of the Master Policy, as evidenced by the Certificate of Insurance, and subject to all other Terms and conditions of the Master Policy, the following changes are effective July 1, 2020.
The following provision is added:
PUBLIC HEALTH EMERGENCY: Subject to all other Terms of this insurance, in the event of a Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster, that may affect an Insured Person’s health, the Company will cover an Illness or Injury incurred during the Period of Coverage and caused by the Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster when, prior to the issuance of a Travel Warning for the Host Country/Destination Country or a Global Travel Warning:
1) the Effective Date of Coverage has occurred; and
2) the Insured Person has arrived in the Host Country/Destination Country or Affected Area.
In the event that the applicable Travel Warning is removed for the Host Country/Destination Country or Affected Area, coverage for an Illness or Injury incurred during the Period of Coverage after the Travel Warning is removed, which was caused by the Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster will be considered by the Company the same as any other Illness or Injury, subject to all other Terms and conditions of this insurance.
COVID-19/SARS-CoV-2 is not applicable to this provision.
The following is added to the ELIGIBLE MEDICAL EXPENSES provision:
Charges for Treatment resulting from COVID-19/SARS-CoV-2
The following is deleted in its entirety from the EXCLUSIONS provision:
any Illness or Injury incurred in the Host Country/Destination Country as a result of epidemics, pandemics, public health emergencies, Natural Disasters, or other disease outbreak conditions that may affect a person’s health when, prior to the Insured Person’s entry into the Host Country/Destination Country, any of the following were issued regarding the Host Country/Destination Country:
(a) the World Health Organization had issued a Travel Warning or Emergency Travel Advisory
(b) the United States Centers for Disease Control & Prevention had issued a Warning Level 3 (avoid nonessential travel)
(c) a similar governmental agency of the Insured Person’s Home Country/Country of Residence had published, communicated or issued a Travel Warning or Emergency Travel Advisory restriction or official declaration informing the public about such health issues before the Insured Person traveled to the Host Country/Country of Residence
and replaced with:
any Illness or Injury incurred in the Host Country/Destination Country, Affected Area or Home Country/Country of Residence as a result of a Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster, that may affect an Insured Person’s health, unless coverage is expressly provided under the PUBLIC HEALTH EMERGENCY provision of this insurance
This exclusion DOES NOT apply to Charges resulting from COVID-19/SARS-CoV-2.
The following defined Terms are added to the DEFINITIONS provision:
Affected Area(s): Any and all countries, states, provinces, territories, cities or other areas experiencing ongoing transmission of an Epidemic, Pandemic or other disease outbreak, or Natural Disaster.
Epidemic: The occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time.
Global Travel Warning: A published statement, warning or advisory, including any website document, issued by the World Health Organization (WHO), United States Centers for Disease Control & Prevention (CDC), United States Department of State, United States Bureau of Consular Affairs, or similar government or non-governmental agency of the Insured Person’s Home Country/Country of Residence or Host Country/Destination Country, warning that any global travel (travel anywhere) poses serious risks to health, safety and security or exposes the Insured Person to a greater likelihood of life-threatening risks, including all United States Department of State global advisories or global warnings Levels “3 - reconsider travel” and “4 -do not travel” and CDC global advisories or global warnings Level “3 – avoid nonessential travel” or any higher level. For the avoidance of doubt, a Global Travel Warning covers all Affected Areas, including the United States of America and all of its territories.
Natural Disaster: Widespread disruption of human lives by disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm, or other storm, landslide, or other natural catastrophe or event resulting in migration of the human population for its safety. The occurrence must be a disaster that is due entirely to the forces of nature and could not reasonably have been prevented.
Pandemic: A global outbreak of a disease.
Public Health Emergency of International Concern: A formal declaration by the World Health Organization (WHO) of an extraordinary event which is determined to constitute a public health risk through the international spread of disease, Epidemic, Pandemic and potentially requires a coordinated international response.
Travel Warning; Emergency Travel Advisory: A published statement, warning or advisory, including any website document, issued by the World Health Organization (WHO), United States Centers for Disease Control & Prevention (CDC), United Stated Department of State, United States Bureau of Consular Affairs, or similar government or non-governmental agency of the Insured Person’s Home Country/Country of Residence or Host Country/Destination Country, warning that travel to Affected Areas poses serious risks to health, safety and security or exposes the Insured Person to a greater likelihood of life-threatening risks, including all United States Department of State Travel Advisories or Warnings Levels “3 - reconsider travel” and “4 -do not travel” and CDC Travel Advisories or Warnings Level “3 – avoid nonessential travel” or any higher level. For the avoidance of doubt, a Travel Warning covers all specified Affected Areas, including the United States of America as applicable.
Except as expressly provided for in the BENEFIT SUMMARY, all Charges, costs, expenses and/or claims incurred by the Insured Person, and any claim for death or dismemberment benefits, and directly or indirectly relating to or arising or resulting from or in connection with any of the following acts, omissions, events, conditions, Charges, consequences, claims, Treatment (including diagnoses, consultations, tests, examinations and evaluations related thereto), services and/or supplies are expressly excluded from coverage under this insurance, and the Company shall provide no benefits or reimbursements and shall have no liability or obligation for any coverage thereof or therefor:
Acute Pre-Ex Coverage
Maternity & Pre-Existing Condition Rider (Standard Plan Only):
Charges excluded until after 12 months of continuous coverage
Pre-Existing Condition Rider(Platinum Plan Only):
Charges excluded until after 6 months of continuous coverage
The Maternity & Pre-Existing Condition Rider is available for eligible participants. Under this rider, eligible medical expenses for pre-natal care, delivery, post-natal care, and care of newborns can be covered after the insured has maintained coverage continuously for 10 months and the pregnancy is a result of natural insemination. Eligible medical expenses relating to a pre-existing condition can be covered after the insured has maintained coverage continuously for 6 months.
With the Student Health Advantage Plan you may seek treatment with the hospital or doctor of your choice. When seeking treatment in the U.S., you can reduce your out-of-pocket costs by using the independent Preferred Provider Organization (PPO), a separately organized network of hundreds of thousands of established, highly qualified health care physicians and many well-recognized hospitals in the U.S. contracted by IMG. You can quickly search the network through MyIMG. Additionally, to help you locate health care providers outside the U.S., IMG provides its online International Provider AccessSM(IPA), a database of over 17,000 providers.
Renewal of Coverage
Subject to the Terms of the Termination of Master Policy and Termination of Coverage for Insured Persons sections, an Insured Person whose initial Period of Coverage is at least three (3) months can request coverage under this insurance plan to be renewed a minimum of five (5) days until reaching a maximum of sixty (60) continuous months in accordance with and subject to the Terms of the plan then in effect (including the Terms of the then applicable Master Policy) and so long as renewal Premium is paid when due and the Insured Person otherwise continues to meet the applicable eligibility requirements of the plan.
The Company’s commitment and the Insured Person’s ability to renew is also subject to termination upon thirty (30) days written notice to the other party prior to the expiration date of the then existing Period of Coverage. The Company reserves the right in its sole discretion to make changes, additions and/or deletions to the Terms of the Master Policy, this Certificate, renewals or replacements of either, and/or to the insurance plan (including the issuance of Riders to effectuate same) at any time or from time to time after the Effective Date of Coverage of this Certificate, upon no less than ninety (90) days prior written notice to the Assured and the Insured Person (“Notice of Amendment”). The Notice of Amendment shall include a complete description of the changes, additions and/or deletions to be made, the effective date thereof (the “Change Date”), and notice of the Insured Person’s cancellation rights as set forth below, and shall be sent first class mail, postage pre-paid, to the last known residence or mailing address of the Insured Person. Upon issuance of the Notice of Amendment, the Assured and/or the Insured Person shall have the right to request cancellation of this Certificate above, at any time prior to the Change Date; provided, however that cancellation under this section shall be at the option of the Insured Person, and coverage under this insurance shall terminate with effect from the cancellation date specified by the Insured Person (subject to the provisions of the Termination of Coverage for Insured Persons section. If the Insured Person does not elect to cancel this Certificate in accordance with the foregoing, the changes, additions and/or deletions as made by the Company and specified in said Notice of Amendment shall take effect as of the Change Date specified in the Company’s Notice, and this insurance shall thereafter continue in effect in accordance with its Terms, as so amended and modified.
Your satisfaction is very important to IMG. If you are not pleased with this product for any reason, you may submit a written request, prior to your effective date, for cancellation and refund of your premium. You may cancel your plan after your effective date if you do not have any claims filed with IMG, however, the following conditions will apply:
- you will be required to pay a $50 cancellation fee and
- only full month premiums will be considered for refunds (e.g., if you choose to cancel your coverage two months and two weeks prior to the date your coverage ends, IMG will only consider the two full months for a refund). If you have filed claims, your premium is non-refundable.
|Before Policy Effective Date:||Full Refund|
|After Policy Effective Date (if no claim filed):||Unused Portion of Premium (Full Remaining Months Only) - $50 Cancellation Fee|
Please send cancellation request at: email@example.com and copy that email to us. Our email is given on Contact Us page.
|Send completed claim documents to International Medical Group|
|Download Claim Forms||Fax||Claim Enquiry|
|firstname.lastname@example.org||1 (317) 655-4505||
P.O. Box 88500, Indianapolis, IN 46208-0500 USA
1 (317) 655-4500
Certain treatment and supplies including hospital admission, inpatient or out-patient surgery, and other procedures as noted in the certificate wording must be precertified for medical necessity, which means the insured person or their attending physician must communicate with an IMG representative at the number listed on the IMG ID card prior to admission to a hospital, before receiving certain treatments and supplies, or performance of a surgery. In case of an emergency admission, the precertification must be made within 48 hours of the admission, or as soon as reasonably possible. If a hospital admission or a surgery is not precertified, eligible claims and expenses will be reduced by 50%. It is important to note that precertification is only a determination of medical necessity, not an assurance of coverage, verification of benefits or a guarantee of payment. All medical expenses eligible for reimbursement must be medically necessary and will be paid or reimbursed at usual, reasonable and customary rates. Please refer to the certificate wording for full details of the precertification requirements.
For Precertification, emergency evacuation and repatriation, please call: IMG in the U.S.: 1.800.628.4664 (toll free) or 1.317.655.4500. Call IMG outside the U.S.: 001.317.655.4500 (collect if necessary). This information will also be provided on your ID card.
Note: You may begin the precertification process through MyIMG or the Client Resources section of imglobal.com. Simply look for the precertification option. You will be asked to provide the required information, which can then be submitted electronically. Once we have received all required information and medical records, our utilization management and review team will review the information provided and normally responds to the insured person or the provider within two business days. Please note that this online service will only initiate the process for treatment and supplies outlined in the contract, and it should not be used to request precertification for emergency admissions, procedures or evacuations.
All benefits payable under Student Health Advantage are subject to the terms and conditions in the certificate of insurance. To make claim processing efficient, claims for eligible medical expenses may be paid in two ways:
- Eligible expenses that have been paid by or on behalf of the insured person may be reimbursed by check directly to the insured person
- Eligible expenses that have not yet been paid by the insured person may, at the option of IMG, be paid either to the insured person or directly to the provider
Claims must be presented to IMG for payment within 180 days from the date the claim was incurred.
Claim form can be submitted online at imglobal.com/member, or emailed to email@example.com, or mailed to International Medical Group, P.O. Box 88500, Indianapolis, IN 46208-0500 USA. IMG may also be contacted by fax at 1.317.655.4505.