Chester Clinic

Iseusa.org

2014–2015
International Injury and Sickness Designed Especially for the International Participants Underwritten by Student Resources (SPC) Ltd. A UnitedHealth Group Company 12C-BR (Rev9-13) Table of Contents Al eligible participants are automatical y enrolled in this insurance Plan. The Company maintains its right to investigate Eligibility or participant status to verify that the policy Eligibility requirements have been met. If the Company discovers that the policy Eligibility requirements have not been met, its only obligation is to refund premium. U.S. citizens are not eligible for coverage as a participant. Effective and Termination Dates The Master Policy becomes effective at 12:01 a.m., February 1, 2015. The individual participant's coverage becomes effective on the first day of the period for which premium is paid or the date the enrol ment form and full premium are received by the Company (or its authorized representative), whichever is later. The Master Policy terminates at 11:59 p.m., January 31, 2017. Coverage terminates on that date or at the end of the period through which premium is paid, whichever is earlier. Twelve (12) months is the maximum time coverage can be effective under any policy year for any Insured person. Refunds of premiums are al owed only upon entry into the armed forces. The Policy is a Non-Renewable Term Policy. Extension of Benefits after Termination The coverage provided under the Policy ceases on the Termination Date. However, if an Insured is Hospital Confined on the Termination Date from a covered Injury or Sickness for which benefits were paid before the Termination Date, Covered Medical Expenses for such Injury or Sickness wil continue to be paid as long as the condition continues but not to exceed 90 days after the Termination Date. The total payments made in respect of the Insured for such condition both before and after the Termination Date wil never exceed the Maximum Benefit. After this "Extension of Benefits" provision has been exhausted, al benefits cease to exist, and under no circumstances wil further payments be made. Pre-Admission Notification UnitedHealthcare should be notified of al Hospital Confinements prior to admission. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS: The patient, Physician or Hospital should telephone 1-877-295-0720 at least five working days prior to the planned admission. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient's representative, Physician or Hospital should telephone 1-877-295-0720 within two working days of the admission to provide notification of any admission due to Medical Emergency. UnitedHealthcare is open for Pre-Admission Notification cal s from 8:00 a.m. to 6:00 p.m. C.S.T., Monday through Friday. Cal s may be left on the Customer Service Department's voice mail after hours by cal ing 1-877-295-0720. IMPORTANT: Failure to follow the notification procedures wil not affect benefits otherwise payable under the policy; however, pre-notification is not a guarantee that benefits wil be paid. Preferred Provider Information "Preferred Providers" are the Physicians, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices. Preferred Providers in the local area are: UnitedHealthcare Options PPO. The availability of specific providers is subject to change without notice. Insureds should always confirm that a Preferred Provider is participating at the time services are required by cal ing the Company at 1-888-251-6246 and/or by asking the provider when making an appointment for services. You can also locate a network provider by logging into My Account at www.uhcsr.com/secutive. "Preferred Allowance" means the amount a Preferred Provider wil accept as payment in ful for Covered Medical Expenses. "Out-of-Network" providers have not agreed to any prearranged fee schedules. Insureds may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment are the Insured's responsibility. Regardless of the provider, each Insured is responsible for the payment of their Deductible. The Deductible must be satisfied before benefits are paid. The Company wil pay according to the benefit limits in the Schedule of Benefits. Inpatient Expenses PREFERRED PROVIDERS – Eligible Inpatient expenses at a Preferred Provider wil be paid at the Coinsurance percentages specified in the Schedule of Benefits, up to any limits specified in the Schedule of Benefits. Cal 1-888-251-6246 for information about Preferred Hospitals. OUT-OF-NETWORK PROVIDERS - If Inpatient care is not provided at a Preferred Provider, eligible Inpatient expenses wil be paid according to the benefit limits in the Schedule of Benefits. Outpatient Hospital Expenses Preferred Providers may discount bil s for outpatient Hospital expenses. Benefits are paid according to the Schedule of Benefits. Insureds are responsible for any amounts that exceed the benefits shown in the Schedule, up to the Preferred Al owance. Professional & Other Expenses Benefits for Covered Medical Expenses provided by UnitedHealthcare Options PPO wil be paid at the Coinsurance percentages specified in the Schedule of Benefits or up to any limits specified in the Schedule of Benefits. Al other providers wil be paid according to the benefit limits in the Schedule of Benefits. Schedule of Medical Expense Benefits Injury and Sickness Benefits Up to $2,000,000 Maximum Benefit (For Each Injury or Sickness) Coinsurance Preferred Providers 100% except as noted below Coinsurance Out-of-Network 100% except as noted below The Preferred Provider for this plan is UnitedHealthcare Options PPO. If care is received from a Preferred Provider, any Covered Medical Expenses wil be paid at the Preferred Provider level of benefits. The Policy provides benefits for the Covered Medical Expense incurred by an Insured Person for loss due to a covered Injury or Sickness up to the Maximum Benefit of $2,000,000 for each Injury or Sickness. Benefits are subject to the policy Maximum Benefit unless otherwise specifical y stated. Benefits wil be paid up to the maximum benefit for each service as scheduled below. Al benefit maximums are combined Preferred Provider and Out-of-Network unless otherwise specifical y stated. Covered Medical Expenses include: Inpatient Preferred Provider Room & Board Expense, daily semi-private Preferred Al owance Usual and Customary Charges room rate when confined as an Inpatient; general nursing care provided by the Hospital. Intensive Care Preferred Al owance Usual and Customary Charges Hospital Miscellaneous Expenses, such Preferred Al owance Usual and Customary Charges as the cost of the operating room, laboratory tests, x-ray examinations, anesthesia, drugs (excluding take home drugs) or medicines, therapeutic services, and supplies. In computing the number of days payable under this benefit, the date of admission wil be counted, but not the date of discharge. Routine Newborn Care Preferred Al owance Usual and Customary Charges Surgeon's Fees, if two or more procedures Preferred Al owance Usual and Customary Charges are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid wil not exceed 50% of the second procedure and 50% of al subsequent procedures. Assistant Surgeon Preferred Al owance Usual and Customary Charges Anesthetist, professional services Preferred Al owance Usual and Customary Charges administered in connection with inpatient surgery. Registered Nurse's Services, private duty Preferred Al owance Usual and Customary Charges nursing care. Physician's Visits, non-surgical services Preferred Al owance Usual and Customary Charges when confined as an Inpatient. Benefits do not apply when related to surgery. Pre-Admission Testing, payable within 3 Preferred Al owance Usual and Customary Charges working days prior to admission. Preferred Provider Surgeon's Fees, if two or more procedures Preferred Al owance Usual and Customary Charges are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid wil not exceed 50% of the second procedure and 50% of al subsequent procedures. Day Surgery Miscellaneous, related to Preferred Al owance Usual and Customary Charges scheduled surgery performed in a Hospital, including the cost of the operating room; laboratory tests and x-ray examinations, including professional fees; anesthesia; drugs or medicines; and supplies. Usual and Customary Charges for Day Surgery Miscellaneous are based on the Outpatient Surgical Facility Charge Index. Assistant Surgeon Preferred Al owance Usual and Customary Charges Anesthetist, professional services Preferred Al owance Usual and Customary Charges administered in connection with outpatient surgery. Physician's Visits, benefits for Physician's Preferred Al owance Usual and Customary Charges Visits do not apply when related to surgery or Physiotherapy. Physiotherapy, see exclusion number 40 Preferred Al owance Usual and Customary Charges for additional limitations. Physiotherapy includes but is not limited to the following: 1) physical therapy; 2) occupational therapy; 3) cardiac rehabilitation therapy; 4) manipulative treatment; and 5) speech therapy, unless excluded in the policy. ($2,500 maximum (Per Policy Year)) Medical Emergency Expenses, facility Preferred Al owance Usual and Customary Charges charge for use of the emergency room and $250 Copay per Sickness $250 Deductible per Sickness supplies. Treatment must be rendered within 72 hours from time of Injury or first onset of Sickness. (The Copay/per service Deductible wil be waived if admitted.) (The Copay/per service Deductible does not apply to Injury.) Diagnostic X-ray Services Preferred Al owance Usual and Customary Charges Radiation Therapy Preferred Al owance Usual and Customary Charges Laboratory Services Preferred Al owance Usual and Customary Charges Tests and Procedures, diagnostic services Preferred Al owance Usual and Customary Charges and medical procedures performed by a Physician, other than Physician's Visits, Physiotherapy, x-rays and lab procedures. The fol owing therapies wil be paid under this benefit: inhalation therapy, infusion therapy, pulmonary therapy and respiratory therapy. Injections, when administered in the Preferred Al owance Usual and Customary Charges Physician's office and charged on the Physician's statement. Chemotherapy Preferred Al owance Usual and Customary Charges Prescription Drugs Usual and Customary Charges Usual and Customary Charges Preferred Provider Ambulance Services Preferred Al owance Usual and Customary Charges Durable Medical Equipment, a written Preferred Al owance Usual and Customary Charges prescription must accompany the claim when submitted. Benefits are limited to the initial purchase or one replacement purchase per Policy Year. Durable Medical Equipment includes external prosthetic devices that replace a limb or body part but does not include any device that is ful y implanted into the body. Consultant Physician Fees, when Preferred Al owance Usual and Customary Charges requested and approved by the attending Physician. Dental Treatment, Benefits paid on Injury 100% of Usual and Customary 100% of Usual and Customary and relief of sudden and unexpected pain to Charges Sound, Natural Teeth only. ($200 maximum per tooth) Maternity Complications of Pregnancy Elective Abortion Mental Illness Treatment Paid as any other Sickness Paid as any other Sickness (Inpatient: NO BENEFITS, Outpatient: 1 visit Per Policy Year, $500 maximum per visit) Substance Use Disorder Treatment Diabetes Services Reconstructive Breast Surgery Following Paid as any other Sickness Paid as any other Sickness Mastectomy, in connection with a covered mastectomy for: 1) al stages of reconstruction of the breast on which the mastectomy has been performed; 2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3) prostheses and physical complications of mastectomy, including lymphedemas. Home Health Care, services received from Preferred Al owance Usual and Customary Charges a licensed home health agency that are ordered by a Physician, provided or supervised by a Registered Nurse in the Insured Person's home, and pursuant to a home health plan. Skilled Nursing Facility, services received Preferred Al owance Usual and Customary Charges while confined as a ful -time Inpatient in a licensed Skil ed Nursing Facility in lieu of or within 24 hours fol owing a Hospital Confinement. Excess Provision Even if you have other insurance, the Plan may cover unpaid balances, Deductibles and pay those eligible medical expenses not covered by other insurance, or under an automobile insurance policy. Benefits wil be paid on the unpaid balances after your other insurance has paid. No benefits are payable for any expense incurred for Injury or Sickness which has been paid or is payable by other valid and collectible insurance or under an automobile insurance policy. However, this Excess Provision wil not be applied to the first $100 of medical expenses incurred. Covered Medical Expenses excludes amounts not covered by the primary carrier due to penalties imposed as a result of the Insured's failure to comply with policy provisions or requirements. Important: The Excess Provision has no practical application if you do not have other medical insurance or if your other insurance does not cover the loss. Accidental Death and Dismemberment Benefits Loss of Life, Limb or Sight If such Injury shal independently of al other causes and within 180 days from the date of Injury solely result in any one of the following specific losses, the Insured Person or beneficiary may request the Company to pay the applicable amount below in addition to payment under the Medical Expense Benefits provision. For Loss Of Two or More Members Member means hand, arm, foot, leg, or eye. Loss shal mean with regard to hands or arms and feet or legs, dismemberment by severance at or above the wrist or ankle joint; with regard to eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater) resulting from any one Injury wil be paid. Definitions COINSURANCE means the percentage of Covered Medical Expenses that the Company pays. COMPLICATION OF PREGNANCY means a condition: 1) caused by pregnancy; 2) requiring medical treatment prior to, or subsequent to termination of pregnancy; 3) the diagnosis of which is distinct from pregnancy; and 4) which constitutes a classifiably distinct complication of pregnancy. A condition simply associated with the management of a difficult pregnancy is not considered a complication of pregnancy. COPAY/COPAYMENT means a specified dollar amount that the Insured is required to pay for certain Covered Medical Expenses. COVERED MEDICAL EXPENSES means reasonable charges which are: 1) not in excess of Usual and Customary Charges; 2) not in excess of the Preferred Al owance when the policy includes Preferred Provider benefits and the charges are received from a Preferred Provider; 3) not in excess of the maximum benefit amount payable per service as specified in the Schedule of Benefits; 4) made for services and supplies not excluded under the policy; 5) made for services and supplies which are a Medical Necessity; 6) made for services included in the Schedule of Benefits; and 7) in excess of the amount stated as a Deductible, if any. Covered Medical Expenses wil be deemed "incurred" only: 1) when the covered services are provided; and 2) when a charge is made to the Insured Person for such services. CUSTODIAL CARE means services that are any of the following: Non-health related services, such as assistance in activities. Health-related services that are provided for the primary purpose of meeting the personal needs of the patient or maintaining a level of function (even if the specific services are considered to be skilled services), as opposed to improving that function to an extent that might al ow for a more independent existence. Services that do not require continued administration by trained medical personnel in order to be delivered safely and effectively. DEDUCTIBLE means if an amount is stated in the Schedule of Benefits or any endorsement to this policy as a deductible, it shal mean an amount to be subtracted from the amount or amounts otherwise payable as Covered Medical Expenses before payment of any benefit is made. The deductible wil apply as specified in the Schedule of Benefits. ELECTIVE SURGERY OR ELECTIVE TREATMENT means those health care services or supplies that do not meet the health care need for a Sickness or Injury. Elective surgery or elective treatment includes any service, treatment or supplies that: 1) are deemed by the Company to be research or experimental; or 2) are not recognized and general y accepted medical practices in the United States. HOSPITAL means a licensed or properly accredited general hospital which: 1) is open at al times; 2) is operated primarily and continuously for the treatment of and surgery for sick and injured persons as inpatients; 3) is under the supervision of a staff of one or more legal y qualified Physicians available at al times; 4) continuously provides on the premises 24 hour nursing service by Registered Nurses; 5) provides organized facilities for diagnosis and major surgery on the premises; and 6) is not primarily a clinic, nursing, rest or convalescent home. HOSPITAL CONFINED/HOSPITAL CONFINEMENT means confinement as an Inpatient in a Hospital by reason of an Injury or Sickness for which benefits are payable. INJURY means bodily injury which is al of the following: directly and independently caused by specific accidental contact with another body or object. unrelated to any pathological, functional, or structural disorder. a source of loss. treated by a Physician within 30 days after the date of accident. sustained while the Insured Person is covered under this policy. Al injuries sustained in one accident, including al related conditions and recurrent symptoms of these injuries wil be considered one injury. Injury does not include loss which results wholly or in part, directly or indirectly, from disease or other bodily infirmity. Covered Medical Expenses incurred as a result of an injury that occurred prior to this policy's Effective Date wil be considered a Sickness under this policy. INPATIENT means an uninterrupted confinement that follows formal admission to a Hospital or Skil ed Nursing Facility by reason of an Injury or Sickness for which benefits are payable under this policy. INSURED PERSON means the Named Insured. The term "Insured" also means Insured Person. INTENSIVE CARE means: 1) a specifical y designated facility of the Hospital that provides the highest level of medical care; and 2) which is restricted to those patients who are critical y il or injured. Such facility must be separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement. They must be: 1) permanently equipped with special life-saving equipment for the care of the critical y il or injured; and 2) under constant and continuous observation by nursing staff assigned on a ful -time basis, exclusively to the intensive care unit. Intensive care does not mean any of these step-down units: Progressive care. Sub-acute intensive care. Intermediate care units. Private monitored rooms. Observation units. Other facilities which do not meet the standards for intensive care. MEDICAL EMERGENCY means the occurrence of a sudden, serious and unexpected Sickness or Injury. In the absence of immediate medical attention, a reasonable person could believe this condition would result in any of the fol owing: Placement of the Insured's health in jeopardy. Serious impairment of bodily functions. Serious dysfunction of any body organ or part. In the case of a pregnant woman, serious jeopardy to the health of the fetus. Expenses incurred for "Medical Emergency" wil be paid only for Sickness or Injury which fulfil s the above conditions. These expenses wil not be paid for minor Injuries or minor Sicknesses. MEDICAL NECESSITY means those services or supplies provided or prescribed by a Hospital or Physician which are al of the following: Essential for the symptoms and diagnosis or treatment of the Sickness or Injury. Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury. In accordance with the standards of good medical practice. Not primarily for the convenience of the Insured, or the Insured's Physician. The most appropriate supply or level of service which can safely be provided to the Insured. The Medical Necessity of being confined as an Inpatient means that both: The Insured requires acute care as a bed patient. The Insured cannot receive safe and adequate care as an outpatient. This policy only provides payment for services, procedures and supplies which are a Medical Necessity. No benefits wil be paid for expenses which are determined not to be a Medical Necessity, including any or al days of Inpatient confinement. MENTAL ILLNESS means a Sickness that is a mental, emotional or behavioral disorder listed in the mental health or psychiatric diagnostic categories in the current Diagnostic and Statistical Manual of the American Psychiatric Association. The fact that a disorder is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a Covered Medical Expense. If not excluded or defined elsewhere in the policy, al mental health or psychiatric diagnoses are considered one Sickness. NAMED INSURED means an eligible, participant, if: 1) the participant is properly enrolled in the program; and 2) the appropriate premium for coverage has been paid. PHYSICIAN means a legal y qualified licensed practitioner of the healing arts who provides care within the scope of his/her license, other than a member of the person's immediate family. The term "member of the immediate family" means any person related to an Insured Person within the third degree by the laws of consanguinity or affinity. PHYSIOTHERAPY means any form of the fol owing short-term rehabilitation therapies: physical or mechanical therapy; diathermy; ultra-sonic therapy; heat treatment in any form; manipulation or massage administered by a Physician. POLICY YEAR means the period of time beginning on the policy Effective Date and ending on the policy Termination Date. PRE-EXISTING CONDITION means: 1) the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within the 6 months immediately prior to the Insured's Effective Date under the policy; or, 2) any condition which originates, is diagnosed, treated or recommended for treatment within the 6 months immediately prior to the Insured's Effective Date under the policy. PRESCRIPTION DRUGS mean: 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a prescription legend drug; 3) any other drugs which under the applicable law may be dispensed only upon written prescription of a Physician; and 4) injectable insulin. REGISTERED NURSE means a professional nurse (R.N.) who is not a member of the Insured Person's immediate family. SICKNESS means sickness or disease of the Insured Person which causes loss, and originates while the Insured Person is covered under this policy. Al related conditions and recurrent symptoms of the same or a similar condition wil be considered one sickness. Covered Medical Expenses incurred as a result of an Injury that occurred prior to this policy's Effective Date wil be considered a sickness under this policy. SKILLED NURSING FACILITY means a Hospital or nursing facility that is licensed and operated as required by law. SOUND, NATURAL TEETH means natural teeth, the major portion of the individual tooth is present, regardless of fil ings or caps; and is not carious, abscessed, or defective. SUBSTANCE USE DISORDER means a Sickness that is listed as an alcoholism and substance use disorder in the current Diagnostic and Statistical Manual of the American Psychiatric Association. The fact that a disorder is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a Covered Medical Expense. If not excluded or defined elsewhere in the policy, al alcoholism and substance use disorders are considered one Sickness. USUAL AND CUSTOMARY CHARGES means the lesser of the actual charge or a reasonable charge which is: 1) usual and customary when compared with the charges made for similar services and supplies; and 2) made to persons having similar medical conditions in the locality where service is rendered. The Company uses data from FAIR Health, Inc. to determine Usual and Customary Charges. No payment wil be made under this policy for any expenses incurred which in the judgment of the Company are in excess of Usual and Customary Charges. Exclusions and Limitations No benefits wil be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or supplies for, at, or related to any of the following: 1. Acne; 2. Acupuncture; 3. Al ergy, including al ergy testing; 4. Addiction, such as: nicotine addiction; and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending, shopping, working and religious; codependency; 5. Autistic disease of childhood, hyperkinetic syndromes, milieu therapy, learning disabilities, behavioral problems, intensive behavioral therapies, such as applied behavioral analysis; parent-child problems, attention deficit disorder, conceptual handicap, developmental delay or disorder or mental retardation; 6. Biofeedback; 7. Charges and al costs related to or arising from or in connection with al trips to the host country undertaken for the purpose of securing medical treatment or supplies; 8. Chronic pain disorders; 9. Circumcision; 10. Congenital conditions; 11. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy; 12. Custodial Care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, or places mainly for domiciliary or Custodial Care; extended care in treatment or substance abuse facilities for domiciliary or Custodial Care; 13. Dental treatment, except as specifical y provided in the Schedule of Benefits; 14. Elective Surgery or Elective Treatment; 15. Elective abortion; 16. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects and problems; except when due to a covered Injury or disease process; 17. Flat foot conditions; supportive devices for the foot; subluxations of the foot; fal en arches; weak feet; chronic foot strain; symptomatic complaints of the feet; and routine foot care including the care, cutting and removal of corns, cal uses, toenails, and bunions (except capsular or bone surgery); 18. Genetic medicine or genetic testing, including without limitation amniocentesis, genetic screening, risk assessment, prevention and/or to determine pre-disposition, genetic counseling, and/or gene therapy; 19. Health spa or similar facilities; strengthening programs; 20. Hearing examinations; hearing aids; or cochlear implants; or other treatment for hearing defects and problems, except as a result of an infection or trauma. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process; 21. Hirsutism; alopecia; 22. HIV, AIDS Virus, AIDS related Sickness, ARC Syndrome, and AIDS, including any testing for these conditions and any Sickness arising as complications from these conditions; 23. Hospice care; 24. Hypnosis; 25. Immunizations; preventive medicines or vaccines, except where required for treatment of a covered Injury; 26. Injury caused by, contributed to, or resulting from the addiction to or use of alcohol, intoxicants, hal ucinogenics, il egal drugs, or any drugs or medicines that are not taken in the recommended dosage or for the purpose prescribed by the Insured Person's Physician; 27. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 28. Injury or Sickness inside the Insured's home country; 29. Injury or Sickness outside the United States and its possessions, except when traveling for academic study abroad 30. Injury or Sickness when claims payment and/or coverage is prohibited by applicable law; 31. Injury sustained while (a) participating in any intercollegiate, or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c) while participating in any practice or conditioning program for such sport, contest or competition; 32. Investigational services; 33. Lipectomy; 34. Marital or family counseling; 35. Maternity; pregnancy; and Complications of Pregnancy; 36. Mental Illness; Substance Use Disorders, except as specifical y provided in the policy; 37. Nuclear, chemical or biological Contamination, whether direct or indirect. "Contamination" means the contamination or poisoning of people by nuclear and/or chemical and/or biological substances which cause Sickness and/or death; 38. Organ transplants, including organ donation; 39. Orthoptics, visual therapy or visual eye training; 40. Outpatient Physiotherapy; except for a condition that required surgery or Hospital Confinement: 1) within the 90 days immediately preceding such Physiotherapy; or 2) within the 90 days immediately fol owing the attending Physician's release for rehabilitation; 41. Participation in a riot or civil disorder; commission of or attempt to commit a felony; 42. Pre-existing Conditions; 43. Prescription Drugs, services or supplies as fol ows: a. Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non- medical substances, regardless of intended use; b. Birth control and/or contraceptives, oral or other, whether medication or device, regardless of intended use; c. Immunization agents, biological sera, blood or blood products administered on an outpatient basis; d. Drugs labeled, "Caution - limited by federal law to investigational use" or experimental drugs; e. Products used for cosmetic purposes; f. Drugs used to treat or cure baldness; anabolic steroids used for body building; g. Anorectics - drugs used for the purpose of weight control; h. Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or i. Growth hormones; or j. Refil s in excess of the number specified or dispensed after one (1) year of date of the prescription. 44. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; female sterilization procedures; vasectomy; sexual reassignment surgery; reversal of sterilization procedures; 45. Research or examinations relating to research studies, or any treatment for which the patient or the patient's representative must sign an informed consent document identifying the treatment in which the patient is to participate as a research study or clinical research study; 46. Routine Newborn Infant Care, wel -baby nursery and related Physician charges; 47. Preventive care services; routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; 48. Services provided normal y without charge by the Health Service of the institution attended by the Insured; 49. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery, except for treatment of a covered Injury or treatment of chronic purulent sinusitis; 50. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; 51. Sleep disorders; 52. Speech therapy; naturopathic services; 53. Suicide or attempted suicide while sane or insane (including drug overdose); or intentional y self-inflicted Injury; 54. Supplies, except as specifical y provided in the policy; 55. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifical y provided in the policy; 56. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; 57. Venereal disease; 58. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium wil be refunded upon request for such period not covered); and 59. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat, and treatment of eating disorders such as bulimia and anorexia. FrontierMEDEX: Global Emergency Medical Assistance If you are a participant insured with this insurance plan, you are eligible for FrontierMEDEX. The requirements to receive these services are as fol ows: International Participants: You are eligible to receive FrontierMEDEX services worldwide, except in your home country. The Emergency Medical Evacuation services are not meant to be used in lieu of or replace local emergency services such as an ambulance requested through emergency 911 telephone assistance. Al services must be arranged and provided by FrontierMEDEX; any services not arranged by FrontierMEDEX wil not be considered for payment. If the condition is an emergency, You should go immediately to the nearest physician or hospital without delay and then contact the 24-hour Emergency Response Center. We wil then take the appropriate action to assist You and monitor Your care until the situation is resolved. Key Services include:  Transfer of Insurance Information to Medical Providers  Monitoring of Treatment  Transfer of Medical Records  Medication, Vaccine and Blood Transfers  Worldwide Medical and Dental Referrals  Dispatch of Doctors/Specialists  Emergency Medical Evacuation  Facilitation of Hospital Admittance Payments (when included with Your enrollment in a UnitedHealthcare StudentResources health insurance policy)  Transportation to Join a Hospitalized Participant  Transportation After Stabilization  Replacement of Corrective Lenses and Medical Devices  Emergency Travel Arrangements  Hotel Arrangements for Convalescence  Continuous Updates to Family and Home Physician  Return of Dependent Children  Replacement of Lost or Stolen Travel Documents  Repatriation of Mortal Remains  Worldwide Destination Intelligence Destination Profiles  Legal Referral  Transfer of Funds  Message Transmittals  Translation Services Please visit www.uhcsr.com/frontiermedex for the FrontierMEDEX brochure which includes service descriptions and program exclusions and limitations. To access services please cal : (800) 527-0218 Toll-free within the United States (410) 453-6330 Collect outside the United States Services are also accessible via e-mail at [email protected]. When cal ing the FrontierMEDEX Operations Center, please be prepared to provide: Cal er's name, telephone and (if possible) fax number, and relationship to the patient; Patient's name, age, sex, and FrontierMEDEX ID Number as listed on your Medical ID Card; Description of the patient's condition; Name, location, and telephone number of hospital, if applicable; Name and telephone number of the attending physician; and Information of where the physician can be immediately reached. FrontierMEDEX is not travel or medical insurance but a service provider for emergency medical assistance services. Al medical costs incurred should be submitted to your health plan and are subject to the policy limits of your health coverage. Al assistance services must be arranged and provided by FrontierMEDEX. Claims for reimbursement of services not provided by FrontierMEDEX wil not be accepted. Please refer to the FrontierMEDEX information in My Account at www.uhcsr.com/MyAccount for additional information, including limitations and exclusions. Nurseline Insured Participants have immediate access to nurse advice 24 hours a day, 7 days a week by dialing the toll-free number listed on the ID card. Col egiate Assistance Program (CAP) is staffed by Registered Nurses, both English and Spanish speaking. CAP's Nurseline services empower people with information, support, and guidance. From helping prepare questions for an upcoming doctor visit to determining the appropriate use of medical resources, Nurseline helps participants make educated decisions about their personal health. Translation services for over 170 languages are available when participants speak to a nurse. Online Access to Account Information UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs, ID Cards, network providers, correspondence and coverage information by logging in to My Account at www.uhcsr.com/myaccount. Insured participants who don't already have an online account may simply select the "create My Account Now" link. Follow the simple, onscreen directions to establish an online account in minutes using your 7-digit Insurance ID number or the email address on file. As part of UnitedHealthcare StudentResources' environmental commitment to reducing waste, we've adopted a number of initiatives designed to preserve our precious resources while also protecting the security of a participant's personal health information. My Account now includes Message Center - a self-service tool that provides a quick and easy way to view any email notifications we may have sent. In Message Center, notifications are securely sent directly to the Insured participant's email address. If the Insured participant prefers to receive paper copies, he or she may opt-out of electronic delivery by going into My Email Preferences and making the change there. ID Cards One way we are becoming greener is to no longer automatical y mail out ID Cards. Instead, we wil send an email notification when the digital ID card is available to be downloaded from My Account. An Insured participant may also use My Account to request delivery of a permanent ID card through the mail. UHCSR Mobile App The UHCSR Mobile App is available for download from Google Play or Apple's App Store. Features of the Mobile App include easy access to:  ID Cards – view, save to your device, fax or email directly to your provider.  Provider Search – search for In-Network participating Healthcare or Mental Health providers, cal the office or facility;  Find My Claims – view claims received within the past 60 days for the primary insured; includes Provider, date of service, status, claim amount and amount paid. Claim Procedures for Injury and Sickness Benefits In the event of Injury or Sickness, participants should: 1. Report to their Physician or Hospital. Mail to the address below al medical and hospital bil s along with the patient's name and insured participant's name, address, SR ID number, and Global Secutive policy number under which the participant is insured. A Company claim form is not required for filing a claim. File claim within 30 days of Injury or first treatment for a Sickness. Bil s should be received by the Company within 90 days of service. Bil s submitted after one year wil not be considered for payment except in the absence of legal capacity. The Plan is Underwritten by Student Resources (SPC) Ltd. A UnitedHealth Group Company Submit all Claims or Inquiries to: UnitedHealthcare StudentResources P.O. Box 809025 Dal as, Texas 75380-9025 1-888-251-6246 [email protected] [email protected] Sales/Marketing Services: UnitedHealthcare StudentResources 805 Executive Center Drive West, Suite 220 St. Petersburg, FL 33702 1-800-237-0903 E-Mail: [email protected] Please keep this Brochure as a general summary of the insurance. The Master Policy on file at Global Secutive contains al of the provisions, limitations, exclusions and qualifications of your insurance benefits, some of which may not be included in this Brochure. The Master Policy is the contract and wil govern and control the payment of benefits. This Brochure is based on Policy #2014-202834-51

Source: https://www.iseusa.org/pdfs/insurance/Elite-Detail.pdf