Study USA-HealthCare - PREFERRED500
- You must be under age 65; and
- a. A full-time student at a college or university (excluding online colleges and universities); or
- b. Within 31 days of being a full-time student at a college or university; or
- c. A student under age 19 enrolled in a secondary school; or
- d. A full-time scholar affiliated with an educational institution and performing work or research for at least 30 hours per week; and
- You must be residing outside your home country for the purpose of pursuing international educational activities; and
- You must not have obtained residency status in your host country; and
- If in the U.S., you must hold a valid education-related visa. A copy of the I-20 or DS2019 may be requested.
J-1 and F-1 visa holders: The full-time student/scholar status requirement is waived within the U.S. if you have a valid F-1 visa (including OPT) or a J-1 visa. Full-time status requirements remain in force for individuals holding M-1, or other category visas.
- You be the participant’s legally married spouse, or must be the participant’s unmarried child under age 19 years and chiefly dependent on the participant for support and maintenance; and
- You must accompany the participant abroad on a similar visa or passport while the participant engages in international educational activities; and
- You must be temporarily located outside the participant’s home country; and
- You must not have obtained residency status in the host country.
C. Special Conditions for Newborn or Adopted Children:
- Newborn or adopted children will be automatically covered as dependents for the first 31 days of life provided that the delivery is covered by this insurance or placement occurs while the participant’s coverage is in effect. If the delivery of the newborn is not covered under this insurance, the newborn is eligible for coverage beginning at 14 days of age.
- Newborn and adopted children must be enrolled within the first 31 days after birth for newborns or within 31 days of placement for adoptions. Enrollment requires written notification of the new dependent’s name, birth date, gender, and citizenship as well as payment of any additional premium due.
- If a newborn or adopted child is not enrolled by the 31st day following birth (for newborns) or placement (for adopted children), then coverage terminates on the 31st day.
Certificate Effective Date
Insurance hereunder is effective on the later of:
- The moment we receive application and correct premium if application and payment is made online or by fax; or
- 12:01am U.S .Eastern Time on the date we receive application and correct premium if application and payment is made by mail; or
- The moment you depart from your home country; or
- 12:01am U.S. Eastern Time on the date requested on the application.
Certificate Termination Date
Insurance hereunder terminates on the earlier of:
- 11:59pm U.S. Eastern Time on the last day of the period for which premium has been paid; or
- 11:59pm U.S. Eastern Time on the date requested on the application; or
- 12:01am U.S. Eastern Time on the date you no longer meet eligibility requirements; or
- The moment of arrival upon your return to your home country (unless you have started a benefit period or are eligible for home country coverage).
Schedule of Benefits and Limits
Except as specifically indicated otherwise, all benefits are subject to deductible, coinsurance, and are per certificate period.
|Overall Maximum Limit||$500,000
(Excludes Emergency Medical Evacuation, Accidental Death and Dismemberment, Repatriation of Remains, and Emergency Reunion)
|Maximum per Injury / Illness||$500,000|
|Deductibles (except Emergency Room)||$25 per injury or illness within the Preferred Provider Organization (PPO) or student health center; otherwise $50 per injury or Illness.
If treatment received outside of U.S., $25 per illness or injury.
|Emergency Room Deductible –Claims incurred in U.S.||$100 for treatment received in an emergency room unless admitted as inpatient.|
|Coinsurance – Claims incurred in U.S.||Within the PPO, we will pay 80% of the next $25,000 of eligible expenses after the deductible, then 100% to the overall maximum limit.
Outside the PPO, we will pay 70% of the next $25,000 of eligible expenses after the deductible, then 100% to the overall maximum limit.
|Coinsurance – Claims incurred outside U.S.||We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.|
|Subject to deductible, coinsurance, and per certificate period unless specifically indicated otherwise|
|Hospital Room and Board||Average semi-private room rate, including nursing services|
|Intensive Care Unit||Usual, reasonable and customary charges|
|Local Ambulance||$350 per injury or illness, when covered illness or injury results in hospitalization as inpatient.|
|Outpatient Treatment||Usual, reasonable and customary charges|
|Outpatient Prescription Drugs||$10 copay for generic drugs
$20 copay for brand name
|Mental Health Disorders (includes drug abuse and alcohol abuse)||Outpatient: Within the PPO, we will pay 80% of eligible expenses up to the overall maximum or 60% outside the PPO. Maximum of 30 visits.
Inpatient: Within the PPO, we will pay 80% of eligible expenses up to the overall maximum or 60% outside the PPO. Maximum of 30 days.
Treatment must not be provided at a student health center.
|Maternity Care for a Covered Pregnancy||We will pay 80% of eligible expenses up to the overall maximum or 70% outside the PPO.|
|Nursery Care of Newborn||$750|
|Therapeutic Termination of Pregnancy||$500|
|Physical Therapy and Chiropractic Care||$75 per visit per day
Must be ordered in advance by a physician and not obtained at a student health center
|Dental Treatment due to Accident||$1,000 maximum per certificate period|
|Wellness||100% of one routine physical exam per member|
|Intercollegiate, Interscholastic, Intramural, or Club Sports||$5,000 maximum per injury or illness, medical expenses only|
|Terrorism||$50,000 lifetime maximum, eligible medical expenses only.|
|All Other Eligible Medical Expenses||Usual, reasonable and customary charges|
|Not Subject to Deductible or Coinsurance|
|Dental Treatment to alleviate pain||$100|
|Emergency Medical Evacuation||$500,000 lifetime maximum|
|Repatriation of Remains||$25,000 lifetime maximum|
|Emergency Reunion||$5,000, subject to a maximum of 15 days|
|Accidental Death & Dismemberment||Lifetime Maximum - $25,000
Death - $25,000
Loss of 2 Limbs - $25,000
Loss of 1 Limb - $12,500
|Personal Liability||$250,000 lifetime maximum
$250,000 third person injury
$250,000 third person property
$2,500 related third person property
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.
Home Country Coverage
- Benefit Period – 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, eligible medical expenses are covered up to a maximum of 15 days for any three month period. 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.
Charges for the following conditions, treatments (including diagnoses, tests, and examinations), services, supplies, acts, omissions, and/or events are excluded from coverage hereunder:
- Congenital illnesses.
- Immunizations and other diagnostic labs, x-rays, and procedures for screening or preventative purposes.
- Dental treatment and treatment of the temporomandibular joint, except for emergency dental treatment necessary to replace sound natural teeth lost or damaged in an accident covered hereunder or for the emergency relief of acute onset of pain.
- Mental health disorders if treatment is obtained at a student health center.
- Physical therapy if treatment is obtained at a student health center.
- Chiropractic treatment, unless ordered in advance by a physician for medically necessary treatment related to a covered injury or illness, and not obtained at a student health center.
- Routine pre-natal care, pregnancy, child birth, post-natal care, and nursery care of a newborn, unless directly related to a covered pregnancy.
- Elective termination of pregnancy.
- Promotion or prevention of conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
- Venereal disease, including all sexually transmitted diseases and conditions.
- HIV, AIDS, or ARC, and all diseases caused by and/or related to HIV.
- Organ or tissue transplants or related services.
- Self-inflicted injury or illness and/or suicide or attempted suicide whether sane or insane.
- Injury sustained that is due wholly or partially to the effects of intoxication or drugs other than drugs taken in accordance with treatment prescribed by a physician and except drugs prescribed for the treatment of substance abuse.
- Voluntarily using any drug, narcotic or controlled substance, unless as prescribed by a physician.
- Charges resulting from or occurring during the commission of a violation of law, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
- Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
- Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations.
- Orthoptics and visual eye training.
- Orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or toenails.
- Hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed.
- Acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, hypertrophic and atrophic conditions of skin, nevus.
- Sleep apnea or other sleep disorders.
- Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.
- Psychometric, intelligence, competency, behavioral and educational testing.
- While confined primarily to receive custodial care, educational or rehabilitative care, or any medical treatment in any establishment for the care of the aged, except rehabilitative care received upon direct transfer from an acute care hospital.
- Cosmetic or aesthetic reasons, except for reconstructive surgery when such surgery is directly related to and follows a surgery which was covered hereunder.
- Modifications of the physical body intended to improve the psychological, mental or emotional well-being, including but not limited to sex-change surgery.
- Obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass surgery.
- Exercise programs, whether or not prescribed or recommended by a physician.
- Incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
- Charges resulting from a disease outbreak in a country or location for which the U.S. Centers for Disease Control and Prevention (CDC) has issued a Level 3 Travel Warning if a) the warning has been in effect within the 6 months immediately prior to your date of arrival, or b) within 10 days following the date the warning is issued you have failed to depart the country or location.
- Investigational, experimental or for research purposes.
- Complications or consequences of a treatment or condition not covered hereunder.
- Incurred outside your certificate period.
- Submitted to us for payment more than 60 days after the last day of the certificate period.
- Exceeding usual, reasonable and customary.
- Not medically necessary.
- Not administered by or ordered by a physician.
- Provided by a relative, family member or any person who ordinarily resides with you.
- Provided at no cost to you.
- Telephone consultations or failure to keep a scheduled appointment.
- When departure from the home country is to obtain treatment in the destination country/countries.
- Travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Repatriation of Remains, and Emergency Reunion sections of this insurance.
- Payable under any government system, including the Australian Medicare system.
- War, military action or while on duty as a member of a police or military force unit.
- Not included as Eligible Expenses as described herein.
Acute Pre-Ex Coverage
Charges resulting directly or indirectly from any pre-existing conditions are excluded from this insurance during the first six (6) months of coverage.
Pre-existing Condition means any
- 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;
- 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;
- injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 12 months immediately preceding the certificate effective date.
To comply with the United States Preferred Provider Organization requirements, the Member must receive medical treatment from PPO providers while in the United States. If the Member chooses to comply with the PPO requirements, and the expenses are incurred in a PPO provider, Underwriters will waive the Coinsurance applicable to the expenses.Members may review a listing of Hospitals, Physicians and other medical service providers included in the PPO Network for the area where the Member will be receiving treatment by accessing the Internet website for HCC Medical Insurance Services
Any extension or renewal is based upon the eligibility rules in force at the time of renewal and is solely at the discretion of Underwriter.
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:
- A $25 cancellation fee will apply for administrative costs incurred by us; and
- 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
- You cannot have filed any claims to be eligible for premium refund; and
- No refund of premium shall be granted after 60 days.
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 is to 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
Proof of Claim
When we receive notice of claim, we will provide you with forms for filing proof of claim. The following is considered to be proof of claim:
- A completed and signed Claimant’s Statement and Authorization form, together with any/all required attachments; and
- Original itemized bills from physicians, hospitals and other medical providers; and
- Original receipts for any expenses which have already been paid by you or on your behalf.
You shall have 60 days beginning on the last day of the certificate period to submit proof of claim to us (unless medical services were rendered after the certificate termination date, in which case you shall 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.
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.
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.
If any dispute shall arise as to the amount to be paid under this insurance such dispute shall be referred to arbitration in accordance with procedures of the American Arbitration Association. 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.