All benefits are per covered individual and for covered conditions. All benefits, except Accidental Death & Dismemberment, are subject to the Deductible and Coinsurance. Limits apply to all benefits.
| Schedule of Benefits and Limits |
| |
Select Plan |
Budget Plan |
| Certificate Period Maximum |
$300,000 (Participant)
$50,000 (Spouse)
$50,000 (Child)
|
$250,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child)
|
| Maximum Benefit per Injury or Illness |
$300,000 (Participant)
$50,000 (Spouse)
$50,000 (Child)
|
$250,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child)
|
| Deductible |
$100 per Injury or Illness
Reduced to $50 if treatment is from Student Health Center
|
| Coinsurance - Claims incurred oustide of US |
After the Deductible, Underwriters will pay 100% of Eligible Expenses to Certificate Period Maximum
|
For the Certificate Period, Underwriters will pay 80% of the next $10,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit
|
| Coinsurance - Claims incurred in US |
For the Certificate Period, Underwriters will pay 80% of the next $5,000 of Eligible Expenses after the Deductible, then 100% to the Certificate Period Maximum
For charges incurred within the PPO or at a Student Health Center, coinsurance will be waived.
|
For the Certificate Period, Underwriters will pay 80% of the next $10,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit
|
| Hospital Room & Board |
Average semi-private room rate, including nursing services |
| Local Ambulance |
Up to $350 per Injury / Illness if Hospitalized as Inpatient |
| Intensive Care Unit |
Usual, Reasonable, and Customary charges |
| Hospital Pre-Notification Penalty |
50% of Eligible Medical Expenses |
| Outpatient Treatment |
Usual, Reasonable, and Customary charges |
| Outpatient Prescription Drugs |
50% of Actual Charge |
| Mental Health Disorders |
Outpatient: $50 Maximum per day, $500 Maximum Lifetime
Inpatient: Usual, Reasonable, and Customary charges to $10,000 Maximum Lifetime
Treatment must be not obtained at a Student Health Center
|
| Dental Treatment due to Accident |
$250 Maximum per tooth
$500 Maximum per Certificate Period
|
| Dental Treatment to Alleviate Pain |
$100 Maximum per Certificate Period
|
| Maternity Care for a Covered Pregnancy |
Usual, Reasonable, and Customary Charges
|
| Routine Nursery Care of Newborn |
$750 Maximum per Certificate Period |
$250 Maximum per Certificate Period |
| Therapeutic Termination of Pregnancy |
$500 Maximum per Certificate Period |
| Physical Therapy & Chiropractic Care |
Maximum $50 per visit per day
Must be ordered in advance by a Physician and not obtained at a Student Health Center
|
| Intercollegiate, interscholastic, intramural, or club sports |
$5,000 Maximum per Injury / Illness
Medical Expenses only
|
| Terrorism |
$50,000 Maximum Lifetime Limit, Medical Expenses Only |
| Benefit Period for Coverage after Policy Termination Date |
60 days from date of Injury or Onset of Illness if Member is Hospitalized on the Termination Date
|
| Emergency Medical Evacuation |
$300,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child) |
$250,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child) |
| Emergency Reunion |
$2,500 Lifetime |
$1,000 Lifetime |
| Accidental Death & Dismemberment |
Principal Sum
$25,000 (Participant)
$10,000 (Spouse)
$ 5,000 (Child) |
No coverage |
| Repatriation of Remains |
$25,000 Maximum |
$15,000 Maximum |
