Student Health Advantage - Excluding 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
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.
The Company, through the Plan Administrator, endeavors to maintain a contractual arrangement with one or more independent Preferred Provider Organizations (PPO) that has established and maintains a network of U.S.-based Physicians, Hospitals and other healthcare and health service providers who are contracted separately and directly with the PPO and who may provide re-pricings, discounts or reduced charges for Treatment or supplies provided to the Insured Person. Neither the Company nor the Plan Administrator has any authority or control over the operations or business of the PPO, or over the operations or business of any provider within the independent PPO network. Neither the PPO nor provider within the PPO network nor any of their respective agents, employees or representatives has or shall have any power or authority whatsoever to act for or on behalf of the Company or the Plan Administrator in any respect, including without limitation no power or authority to: (i) approve Applications or enrollments for initial, renewal or reinstated coverage under this insurance plan or to accept Premium payments, (ii) accept risks for or on behalf of the Company, (iii) act for, speak for, or bind the Company or the Plan Administrator in any way, (iv) waive, alter or amend any of the Terms of the Master Policy or this Certificate or waive, release, compromise or settle any of the Company’s rights, remedies, or interests thereunder or hereunder, or (v) determine Pre-certification, eligibility for coverage, verification of benefits, or make any coverage, benefit or claim adjudications or decisions of any kind. It is not a requirement of this insurance that the Insured Person seek Treatment or supplies exclusively from a provider within the independent PPO network. However, the Insured Person’s use or non-use of the PPO network may affect the scope and extent of benefits available under this insurance, including without limitation any applicable Deductible, Coinsurance and benefit reduction, as set forth above. An Insured Person may contact the Company through the Plan Administrator and request a PPO Directory for the area where the Insured Person will be receiving consultation or Treatment (therein listing the Physicians, Hospitals and other healthcare providers within the PPO network by location and specialty), or may visit the Plan Administrator’s website at http://myimglobal.com to obtain such information.
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 monthly for up to 12 month periods and 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: firstname.lastname@example.org and copy that email to us. Our email is given on Contact Us page.
PROOF OF CLAIM
When the Company receives notice of a claim for benefits under this insurance from or on behalf of an Insured Person it will provide the Insured Person with Claimant’s Statement and Authorization Forms (“Claim Forms”) for filing Proof of Claim. The following items must be submitted by or on behalf of the Insured Person to be considered a complete Proof of Claim eligible for consideration of coverage under this insurance (“Proof of Claim”):
- a duly completed, timely submitted, and signed Claim Form and authorization for release of information; and
- all original itemized bills and statements of services rendered from all Physicians, Hospitals and other healthcare or medical service providers involved with respect to the claim; and
- all original receipts for any costs, fees or expenses that have been incurred or paid by or on behalf of the Insured Person with respect to the claim, including without limitation all original receipts for any cash and/or credit card payments.
The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have ninety (90) days from the date a claim is incurred to submit a complete Proof of Claim, and the Company at its option may pend resolution and adjudication of submitted claims and/or may deny coverage: for Proofs of Claim submitted thereafter; or for incomplete Proofs of Claim; and/or for failure to submit a Proof of Claim; provided, however, that the Company at its option may waive the requirements regarding submission of a new Claim Form for subsequent claims incurred by an Insured Person relating to a continuing Illness, Injury or other medical condition for which a properly completed and signed Claim Form has previously been submitted and received.
APPEALING A CLAIM
In the event the Company denies all or part of a claim, the Insured Person shall have a maximum of two mandatory appeal levels to appeal the denial under which there will be a review of the claim and the determination. Insured Persons shall have sixty (60) days from the date that the notice of denial was mailed to the Insured Person's last known residence or mailing address within which to appeal the determination, and shall have the opportunity to submit written comments, documents, records, and other information relating to the claim. The Company’s review will take into account all comments, documents, records, and other information submitted by the Insured Person relating to the claim, without regard to whether such information was submitted or considered in the initial claim determination. Insured Persons must file two (2) appeals of a claim denial prior to bringing any legal action under the contract of insurance. Upon receipt of a written appeal, the Company shall have an opportunity for further reasonable investigation and/or review as set forth in the Explanation or Verification of Benefits section, and will respond in writing as soon as reasonably practicable, and in any event within ninety (90) days from receipt thereof.
Eligible and covered claims for ELIGIBLE MEDICAL EXPENSES or other benefits under this insurance that have previously been paid by or on behalf of the Insured Person at the time of the Company’s favorable adjudication thereof will be reimbursed by the Company directly to the Insured Person, by check, at his/her last known residence or mailing address. While this insurance is in effect, in order to effectuate proper administration the Insured Person shall undertake to promptly notify the Company of any change in such addresses. Eligible and covered claims for ELIGIBLE MEDICAL EXPENSES or other benefits under this insurance that have not been paid by or on behalf of the Insured Person at the time of adjudication will be paid by the Company by check or electronic funds transfer to the Insured Person at his/her last known residence or mailing address, or, at the sole option and discretion of the Company (but without obligation to do so), and as an accommodation to the Insured Person, directly to the provider(s), as applicable. All claim settlements, payments and reimbursements are subject to the insurance plan shown in the Declaration and all other Terms of this insurance. No healthcare or medical service provider or supplier, or any other third-party, shall have any direct or indirect interest, claim or right of action against the Company under this Certificate, the Declaration or the Master Policy, whether by purported assignment of benefits, subrogation of interests or otherwise, unless first expressly agreed and consented to in writing by the Company, and notwithstanding the Company’s exercise or failure to exercise any option or discretion under this provision regarding the method of claim payment. No such provider, supplier or other third-party is intended to have or shall have any rights as a third-party beneficiary under this Certificate, the Declaration, or the Master Policy.
A person who knowingly and with intent to defraud the Company files a statement of claim containing any false, incomplete, or misleading information commits a felony. If any claim or request for benefits under this insurance shall knowingly be in any respect false, incomplete, misleading, concealing, fraudulent or deceitful, or if the Insured Person or anyone acting for or on his/her behalf under this insurance knowingly uses any false, incomplete, misleading, concealing, fraudulent or deceitful statements regarding the Insured Person, the insurance contract and all coverage thereunder may be cancelled, voided, rescinded and terminated by the Company in its sole and absolute discretion, and the Company shall have no obligation or liability for any such benefits, coverage or claims.