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2010-201322-75-brochure-v2.qxp

2010-2011STUDENT INJURY ANDSICKNESS INSURANCEPLAN Holy Names University
Table of Contents
Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Alternative Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Accidental Death & Dismemberment Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Benefits for Severe Mental Illnesses and Serious Emotional Disturbances . . . . . .7Additional Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . .11Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back Cover Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality ofyour nonpublic personal information. We do not disclose any nonpublic personal informationabout our customers or former customers to anyone, except as permitted or required by law.
We believe we maintain appropriate physical, electronic and procedural safeguards toensure the security of your nonpublic personal information. You may obtain a copy of ourprivacy practices by calling us toll-free at 1-800-767-0700 or by visiting us atwww.uhcsr.com.
Eligibility
All registered students are eligible to enroll in this insurance Plan.
Students must actively attend classes for at least the first 31 days after the date for whichcoverage is purchased. Home study, correspondence, Internet and television (TV) coursesdo not fulfill the Eligibility requirements that the student actively attend classes. TheCompany maintains its right to investigate eligibility or student status and attendancerecords to verify that the policy Eligibility requirements have been met. If the Companydiscovers the Eligibility requirements have not been met, its only obligation is to refundpremium.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents arethe spouse or Domestic Partner and unmarried children under 19 years of age or 23 yearsif a full-time student at an accredited institution of higher learning who are not self-supporting. See the Definitions section of the brochure for the specific requirementsneeded to meet Domestic Partner eligibility.
Dependent Eligibility expires concurrently with that of the Insured student.
Effective and Termination Dates
The Master Policy on file at the school becomes effective August 11, 2010. The individualstudent’s coverage becomes effective on the first day of the period for which premium ispaid or the date the enrollment form and full premium are received by the Company (or itsauthorized representative), whichever is later. The Master Policy terminates August 10,2011. Coverage terminates on that date or at the end of the period through which premiumis paid, whichever is earlier. Dependent coverage will not be effective prior to that of theInsured student or extend beyond that of the Insured student. Refunds of premiums are allowed only upon entry into the armed forces. The policy is aNon-Renewable One Year Term Policy.
Alternative Coverage
If you do not meet the Eligibility requirements of this student policy, please call 1-800-406-2338 for information on alternative coverage. You may also access information on this plan,get premium quotes, and apply on-line at our website: http://www.goldenrulehealth.com/studentresources.
Extension of Benefits After Termination
The coverage provided under the Policy ceases on the Termination Date. However, if anInsured is Hospital Confined on the Termination Date from a covered Injury or Sickness forwhich benefits were paid before the Termination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long as the condition continues but not toexceed 90 days after the Termination Date.
The total payments made in respect of the Insured for such condition both before and afterthe Termination Date will never exceed the Maximum Benefit. After this “Extension ofBenefits” provision has been exhausted, all benefits cease to exist, and under nocircumstances will further payments be made.
Pre-Admission Notification
UMR Care Management should be notified of all Hospital Confinements prior to admission.
1. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS: patient, Physician or Hospital should telephone 1-877-295-0720 at least five working daysprior to the planned admission.
2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient’s representative, Physician or Hospital should telephone 1-877-295-0720 within twoworking days of the admission to provide the notification of any admission due toMedical Emergency.
UMR Care Management is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00p.m., C.S.T., Monday through Friday. Calls may be left on the Customer Service Department’svoice mail after hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwisepayable under the policy; however, pre-notification is not a guarantee that benefits will bepaid.
Up To $50,000 Maximum Benefit Paid as Specified Below $50 Deductible (Per Insured Person) (For Each Injury or Sickness) The Policy provides benefits for 80% of the Usual & Customary Charges incurred by anInsured Person for loss due to a covered Injury or Sickness up to the Maximum Benefit of$50,000 for each Injury or Sickness. Benefits will be paid up to the Maximum Benefit for each service as scheduled below.
Covered Medical Expenses include: Hospital Expense, daily semi-private room rate; general nursing care provided by the Hospital. Hospital Miscellaneous Expenses, such 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 numberof days payable under this benefit, the date of admission willbe counted, but not the date of discharge. Routine Newborn Care, While Hospital Confined; and routine nursery care provided immediately after birth. Surgeon’s Fees, in accordance with data provided by Ingenix. If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will notexceed 50% of the second procedure and 50% of allsubsequent procedures.
Registered Nurse’s Services, private duty nursing Physician’s Visits, benefits are limited to one visit per day and do not apply when related to surgery.
Pre-Admission Testing, payable within 3 working days Psychotherapy, benefits are limited to one visit per day. Psychiatric Hospitals are not covered.
Surgeon’s Fees, in accordance with data provided by Ingenix. If two or more procedures are performed through the same incision or in immediate successionat the same operative session, the maximum amountpaid will not exceed 50% of the second procedureand 50% of all subsequent procedures.
Day Surgery Miscel aneous, related to scheduled surgery performed in a Hospital, including the cost of the operating room; laboratory tests and x-rayexaminations, including professional fees; anesthesia;drugs or medicines; and supplies. Usual andCustomary Charges for Day Surgery Miscellaneousare based on the Outpatient Surgical Facility ChargeIndex.
Anesthetist, professional services administered in Outpatient Miscel aneous Benefit, includes benefits designated as Paid under Outpatient Miscellaneous Physician’s Visits, benefits are limited to one visit per day. Benefits for Physician’s Visits do not apply when related to surgery or Physiotherapy.
Physiotherapy, benefits are limited to one visit per day.
(Outpatient Physiotherapy benefits are payable only for a condition that required surgery or HospitalConfinement: 1) within the 30 days immediatelypreceding such Physiotherapy; or 2) within the 30 daysimmediately following the attending Physician's releasefor rehabilitation.) Medical Emergency Expenses, use of the emergency room and supplies. Treatment must be rendered within 72 hours from time of Injury or first onset of Sickness. Tests & Procedures, diagnostic services and medical procedures performed by a Physician, other than Physician’s Visits, Physiotherapy, X-Rays and LabProcedures. Psychotherapy, Benefits are limited to one visit per day. Including all related or ancillary charges incurred as a result of Mental & Nervous Disorder (including Prescription Drugs).
Severe Mental Il ness Durable Medical Equipment, a written prescription must accompany the claim when submitted.
Replacement equipment is not covered.
Consultant Physician Fees, when requested and approved by the attending Physician.
Dental Treatment, made necessary by Injury to Natural Maternity, (Pregnancy will not be considered a pre- Maternity Testing
This policy does not cover routine, preventive or screening examinations or testing unlessMedical Necessity is established based on medical records. The following maternity routinetests and screening exams will be considered if all other policy provisions have been met:Initial screening at first visit – Pregnancy test: Urine human chorionic gonatropin (HCG),Asymptomatic bacteriuria: Urine culture, Blood type and Rh antibody, Rubella, Pregnancy-associated plasma protein-A (PAPPA) (first trimester only), Free beta human chorionicgonadotrophin (hCG) (first trimester only), Hepatitis B: HBsAg, Pap smear, Gonorrhea: Gcculture, Chlamydia: chlamydia culture, Syphilis: RPR, and HIV: HIV-ab; Each visit – Urineanalysis; Once every trimester – Hematocrit and Hemoglobin; Once during first trimester –Ultrasound; Once during second trimester – Ultrasound (anatomy scan); Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen test Alpha-fetoprotein (AFP), Estriol, hCG,inhibin-a; Once during second trimester if age 35 or over - Amniocentesis or Chorionic villussampling (CVS); Once during second or third trimester – 50g Glucola (blood glucose 1 hourpostprandial); and Once during third trimester - Group B Strep Culture. Pre-natal vitaminsare not covered. For additional information regarding Maternity Testing, please call theCompany at 1-800-767-0700.
Accidental Death & Dismemberment Benefit
Loss of Life, Limb or SightIf such Injury shall independently of all other causes and within 180 days from the date ofInjury solely result in any one of the following specific losses, the Insured Person orbeneficiary may request the Company to pay the applicable amount below in lieu ofpayment under the Medical Expense Benefits.
For Loss of: Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or armsand feet or legs, dismemberment by severance at or above the wrist or ankle joint; withregard to eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater)resulting from any one Injury will be paid.
Mandated Benefits
Benefits for Severe Mental Illnesses and Serious Emotional Disturbances Benefits will be paid the same as any other Sickness for the diagnosis and MedicallyNecessary treatment of Severe Mental Illnesses of an Insured of any age and of SeriousEmotional Disturbances of an Insured child as specified below: (1) Outpatient services.
(2) Inpatient hospitalization services. (3) Partial hospitalization services.
(4) Prescription Drugs, if the policy includes coverage for Prescription Drugs.
"Severe Mental Illness" includes: (1) Schizophrenia(2) Schizoaffective disorder(3) Bipolar disorder (manic-depressive disorder)(4) Major depressive disorders(5) Panic disorder(6) Obsessive-Compulsive disorder(7) Pervasive developmental disorder of Autism(8) Anorexia nervosa(9) Bulimia nervosa "Serious emotional disturbance of a child" means a child under the age of 18 years who hasone or more mental disorders as identified in the most recent edition of the Diagnostic andStatistical Manual of Mental Disorders, other than a primary substance use disorder ordevelopmental disorder, that result in behavior inappropriate to the child's age according toexpected developmental norms. Members of this target population must meet one or moreof the following criteria: (A) As a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, orability to function in the community; and either of the following occur: (i) the childis at risk of removal from home or has already been removed from the home. (ii)The mental disorder and impairments have been present for more than 6 monthsor are likely to continue for more than one year without treatment. (B) The child displays one of the following: psychotic features, risk of suicide or risk of (C) The child meets special education eligibility requirements under Chapter 26.5 of division 7 of Title 1 of the Government Code.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Additional Mandated Benefits
Benefits are provided as mandated by California Department of Insurance such as Benefitsfor Diabetes, Telemedicine, Mammography, Upper or Lower Jawbone Surgery,Reconstructive Surgery, Prosthetic Devices for Speaking Post Laryngectomy, ProstateCancer Screening, Cancer Screening Tests, Cervical Cancer Screening, AIDS Vaccine,Phenylketonuria (PKU), Osteoporosis, Cancer Clinical Trials and Breast Cancer Screeningand Treatment. A detail of these benefits may be found in the Master Policy on file at theUniversity.
Definitions
Creditable Coverage means any individual or group policy, contract or program, that iswritten or administered by a disability insurance company, health care service plan, fraternalbenefit society, self-insured employer plan, or any other entity, in this state or elsewhere, andthat arranges or provides medical, hospital, and surgical coverage not designed tosupplement other private or governmental plans, including Medicare or Medicaid, nonprofitmedical and surgical plan or hospital service plan that provides similar benefits, ArmedForces Personnel Medical and Dental Care, Indian Health Service or tribal organizationmedical care program, a state health benefits risk pool, Federal Employees Health BenefitPlan, the Peace Corps Act health benefit plan, health maintenance organization, a publichealth plan, or College Plan. The term includes continuation or conversion coverage, butdoes not include accident only, credit, coverage for onsite medical clinics, disability income,Medicare supplement, long-term care insurance, dental, vision, coverage issued as asupplement to liability insurance, insurance arising out of a workers' compensation or similarlaw, automobile medical payment insurance, or insurance under which benefits are payablewith or without regard to fault and that is statutorily required to be contained in any liabilityinsurance policy or equivalent self-insurance.
Domestic Partner Domestic partners are two adults who have chosen to share oneanother's lives in an intimate and committed relationship of mutual caring and where all ofthe following requirements are met: (1) Both persons have a common residence. (2)Neither person is married to someone else or is a member of another domestic partnershipwith someone else that has not been terminated, dissolved, or adjudged a nullity. (3) Thetwo persons are not related by blood in a way that would prevent them from being marriedto each other in this state. (4) Both persons are at least 18 years of age. (5) Either of thefollowing (A) Both persons are members of the same sex. (B) One or both of the personsmeet the eligibility criteria under Title II of the Social Security Act as defined in 42 U.S.C.
Section 402(a) for old-age insurance benefits or Title XVI of the Social Security Act asdefined in 42 U.S.C. Section 1381 for aged individuals. Notwithstanding any other provisionof this section, persons of opposite sexes may not constitute a domestic partnership unlessone or both of the persons are over the age of 62. (6) Both persons are capable ofconsenting to the domestic partnership.
Injury means bodily injury which is: 1) directly and independently caused by specificaccidental contact with another body or object; 2) unrelated to any pathological, functional,or structural disorder; 3) a source of loss; 4) treated by a Physician within 30 days after thedate of accident; and 5) sustained while the Insured Person is covered under this policy. Allinjuries sustained in one accident, including all related conditions and recurrent symptomsof these injuries will be considered one injury. Injury does not include loss which resultswholly or in part, directly or indirectly, from disease or other bodily infirmity. Covered MedicalExpenses incurred as a result of an injury that occurred prior to this policy's Effective Datewill be considered a Sickness under this policy.
Pre-Existing Condition means any condition for which medical advice, diagnosis, care ortreatment, including the use of Prescription Drugs is recommended or received from aPhysician within 6 months immediately prior to the Insured's Effective Date under the policy.
Sickness means sickness or disease of the Insured Person which causes loss while theInsured Person is covered under this policy. All related conditions and recurrent symptomsof the same or a similar condition will be considered one sickness. Covered MedicalExpenses incurred as a result of an Injury that occurred prior to this policy's Effective Datewill be considered a sickness under this policy.
Usual and Customary Charges means a reasonable charge which is: 1) usual andcustomary when compared with the charges made for similar services and supplies; and 2)made to persons having similar medical conditions in the locality of the Policyholder. Nopayment will be made under this policy for any expenses incurred which in judgement ofthe Company are in excess of Usual and Customary Charges.
Exclusions and Limitations
No benefits will 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: 1. Acne; acupuncture; allergy, including allergy testing;2. Addiction, such as: nicotine addiction and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending, shopping, working and religious; codependency; 3. Assistant Surgeon Fees;4. Biofeedback;5. Radiation Therapy; Injections; Chemotherapy;6. Chronic pain disorders;7. Circumcision;8. Congenital conditions, except as specifically provided for Benefits for Reconstructive Surgery, or for Newborn or adopted Infants; 9. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adopted children;removal of warts, non-malignant moles and lesions; 10. Custodial care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or custodial care;extended care in treatment or substance abuse facilities for domiciliary or custodialcare; 11. Dental treatment, except for accidental Injury to Natural Teeth;12. Elective Surgery or Elective Treatment; 13. Elective abortion;14. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visualdefects and problems; except when due to a disease process; 15. Foot care including: flat foot conditions, supportive devices for the foot, subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toenails,fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet; 16. Health spa or similar facilities; strengthening programs;17. Hearing examinations or hearing aids; or other treatment for hearing defects and problems. "Hearing defects" means any physical defect of the ear which does or canimpair normal hearing, apart from the disease process; 18. Hirsutism; alopecia;19. Hypnosis;20. Immunizations; preventive medicines or vaccines, except where required for treatment of a covered Injury; or as specifically provided in the policy; 21. Loss sustained or contracted in consequence of the Insured’s being intoxicated or under the influence of any controlled substances unless administered on the advice ofa Physician; 22. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 23. Injury sustained while (a) participating in any interscholastic, club, intercollegiate, or professional sport, contest or competition; (b) traveling to or from such sport, contest orcompetition as a participant; or (c) while participating in any practice or conditioningprogram for such sport, contest or competition; 24. Investigational services;25. Lipectomy;26. Organ transplants, including organ donation;27. Outpatient Physiotherapy; except for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2)within the 30 days immediately following the attending Physician's release forrehabilitation; 28. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or 29. Pre-Existing Conditions, except for individuals who have been continuously insured for at least 6 consecutive months under any health insurance plan or policy or employer-provided health benefit arrangement. Credit for time served will be given when coveredunder Creditable Coverage provided the individual becomes eligible and enrolls underthis policy within 63 days of termination of the prior plan; 30. Prescription Drug Services - no benefits will be payable for: a) Therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medical substances, regardless of intendeduse, except as specifically provided in the Benefits for Diabetes; b) Immunization agents, biological sera, blood or blood products administered on c) Drugs labeled, "Caution - limited by federal law to investigational use" or d) Products used for unapproved cosmetic indications;e) Drugs used to treat or cure baldness, and anabolic steroids used for body f) Anorectics - drugs used for the purpose of weight control;g) Fertility agents, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, or h) Growth hormones; ori) Refills in excess of the number specified or dispensed after one (1) year of date 31. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for thepurpose or with the intent of inducing conception; premarital examinations; impotence,organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversal ofsterilization procedures; 32. Research or examinations relating to research studies, or any treatment for which the patient or the patient's representative must sign an informed consent documentidentifying the treatment in which the patient is to participate as a research study orclinical research study; 33. Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery; 34. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness, except as specificallyprovided in the policy; 35. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 36. Deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery, except for treatment of chronic purulent sinusitis; 37. 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 regularlyscheduled flight of a commercial airline; 38. Sleep disorders;39. Speech therapy; naturopathic services;40. Suicide or attempted suicide while sane or insane (including drug overdose); or 41. Supplies, except as specifically provided in the policy;42. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia, except as specifically provided in the policy; 43. Travel in or upon, sitting in or upon, alighting to or from, or working on or around any motorcycle or recreational vehicle including but not limiting to: two- or three-wheeledmotor vehicle; four-wheeled all terrain vehicle (ATV); 44. Treatment in a Government hospital, unless there is a legal obligation for the Insured 45. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered);and 46. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat.
Collegiate Assistance Program
Insured Students have access to nurse advice and health information 24 hours a day, 7days a week by dialing the access number indicated on your permanent ID Card. TheCollegiate Assistance Program is staffed by Registered Nurses who can help studentsdetermine if they need to seek medical care, understand their medications or medicalprocedures, or learn ways to stay healthy.
Scholastic Emergency Services:
Global Emergency Medical Assistance

If you are a student insured with this insurance plan, you and your insuredspouse/Domestic Partner and minor child(ren) are eligible for Scholastic EmergencyServices (SES). The requirements to receive these services are as follows:International Students, insured spouse/Domestic Partner and insured minor child(ren): Youare eligible to receive SES worldwide, except in your home country.
Domestic Students, insured spouse/Domestic Partner and insured minor child(ren): Youare eligible for SES when 100 miles or more away from your campus address and 100miles or more away from your permanent home address or while participating in a StudyAbroad program. SES includes Emergency Medical Evacuation and Return of Mortal Remains that meet theUnited States Department requirements. The Emergency Medical Evacuation services arenot meant to be used in lieu of or replace local emergency services such as an ambulancerequested through emergency 911 telephone assistance. All SES services must bearranged and provided by SES, any services not arranged by SES will not be considered forpayment.
Key Services include: * Medical Consultation, Evaluation and Referrals * Foreign Hospital AdmissionGuarantee* Prescription Assistance * Care for Minor Children Left Unattended Due to a Medical Incident* Lost Luggage or Document Assistance Please visit your school’s insurance coverage page at www.uhcsr.com for the SES GlobalEmergency Assistance Services brochure which includes service descriptions and programexclusions and limitations.
To access services please cal :(877) 488-9833 Toll-free within the United States(609) 452-8570 Collect outside the United StatesServices are also accessible via e-mail at medservices@assistamerica.com. When calling the SES Operations Center, please be prepared to provide: 1. Caller's name, telephone and (if possible) fax number, and relationship to the patient;2. Patient's name, age, sex, and Reference Number;3. Description of the patient's condition;4. Name, location, and telephone number of hospital, if applicable;5. Name and telephone number of the attending physician; or6. Information of where the physician can be immediately reached.
SES is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan andare subject to the policy limits of your health coverage. All assistance services must bearranged and provided by SES. Claims for reimbursement of services not provided by SESwill not be accepted. Please refer to your SES brochure for Program Guidelines as well aslimitations and exclusions pertaining to the SES program.
Online Access to Account Information
UnitedHealthcare StudentResources insured have online access to claims status, EOBs,correspondence and coverage information via My Account at UHCSR.com. Insured canalso print a temporary ID card, request replacement ID card and locate network providerfrom My Account.
If you don’t already have an online account, simply select the “Create an Account” link fromthe home page at UHCSR.com. Follow the simple, onscreen directions to establish anonline account in minutes. Note that you will need your 7-digit insurance ID number tocreate an online account. account information.
Claim Procedure
In the event of Injury or Sickness, students should: 1) Report to the Student Health Service or Infirmary for treatment or referral, or when not in school, to their Physician or Hospital.
2) Mail to the address below all medical and hospital bills along with the patient's name and insured student's name, address, social security number and name of theUniversity under which the student is insured. A Company claim form is not requiredfor filing a claim.
3) Bills should be received by the Company within 90 days of service. Bills submitted after one year will not be considered for payment except in the absence of legalcapacity.
The Plan is Underwritten by:
Submit All Claims or Inquiries to:
805 Executive Center Drive West, Suite 220 Please keep this Brochure as a general summary of the insurance. The Master Policy onfile at the University contains all of the provisions, limitations, exclusions and qualificationsof your insurance benefits, some of which may not be included in this Brochure. The MasterPolicy is the contract and will govern and control the payment of benefits.
This Brochure is based on Policy #2010-201322-75

Source: http://www.hnu.edu/studentLife/documents/2010-201322-75-Brochure-v2.pdf

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