Newhampton.org

2013-2014
STUDENT INJURY AND SICKNESS INSURANCE PLAN
New Hampton School
New Hampshire
Limited Benefit Plan. Please Read Carefully Underwritten by: United States Fire Insurance Co.
SCHEDULE OF MEDICAL EXPENSE BENEFITS-INJURY AND SICKNESS
Up To $250,000 Maximum Benefit (For each Injury or Sickness) Paid as Specified Below- The Policy provides benefits for 100% of the Usual Reasonable and Customary Charges
incurred by an Insured Person for loss due to a covered Injury or Sickness up to the Maximum Benefit of $250,000 for each Injury or Sickness.
Usual Reasonable Customary Charges are based on data provided by FAIR Health, Inc. using the 90th percentile based on location of provider.
The Pre-Existing Conditions are not excluded, therefore the “first manifests itself after the effective date of insurance” statement in Sickness definition does not apply.
Benefits will be paid up to the Maximum Benefit for each service as scheduled below. Covered Medical Expenses include: INPATIENT
Room & Board Expense, daily semi-private room rate; and general nursing care provided by the Hospital. . . . . . . . . . . . . . . . . . URC
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 number of days payable under this benefit, the date of admission will be counted, but not the date of discharge. . . . . . . URC Intensive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Physiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Surgeon’s Fees, 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 not exceed 50% of the second procedure and 50% of all subsequent procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC Assistant Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30% of Surgery Allowance
Anesthetist, professional services administered in connection with inpatient surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Registered Nurse’s Services, private duty nursing care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Physician’s Visits, benefits are limited to one visit per day and do not apply when related to surgery. . . . . . . . . . . . . . . . . . . . . . URC
Pre-Admission Testing, payable within 3 working days prior to hospital admission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Psychotherapy (Mental and Nervous Disorders), benefits limited to one visit per day. Psychiatric Hospital are not covered. . . . Paid as any other Sickness
Biologically Based Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See Benefits for Biologically Based Mental Illness
OUTPATIENT
Surgeon’s Fees, 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 all subsequent procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC Day Surgery Miscellaneous, related to 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. . . URC Assistant Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30% of Surgery Allowance
Anesthetist, professional services administered in connection with outpatient surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Physician’s Visits, benefits are limited to one visit per day. Visits do not apply when related to surgery or Physiotherapy. . . . . . URC
Physiotherapy, benefits are limited to one visit per day. Review of Medical Necessity will be performed after 12 visits
per Injury or Sickness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC Medical Emergency Expense, use of the emergency room and supplies. Treatment must be rendered within 72 hours
from time of Injury or first onset of Sickness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC Diagnostic X-ray and Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Radiation Therapy and Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Tests & Procedures, diagnostic services and medical procedures performed by a Physician, other than Physician’s Visits,
Physiotherapy, X-rays and Lab Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC Injections, when administered in the Physician’s office and charged on the Physician’s statement. . . . . . . . . . . . . . . . . . . . . . . . URC
Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 max
Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,500 max (Per Policy Year).
Psychotherapy (Mental and Nervous Disorders), including all related or ancillary charges incurred as a result of a Mental
& Nervous Disorder. Benefits are limited to one visit per day.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid as any other Sickness
Biologically Based Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See Benefits for Biologically Based Mental Illness
OTHER
Ambulance Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Durable Medical Equipment, a written prescription must accompany the claim when submitted. Replacement
equipment is not covered. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC Consultant Physician Fees, when requested and approved by the attending Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Alcoholism / Chemical Dependency, includes treatment for inpatient, outpatient, detox and rehab. . . . . . . . . . . . . . . . . . . . . . . . $3,000 max
Dental Treatment, made necessary by Injury to Sound, Natural Teeth only. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Maternity & Complications of Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid as any other Sickness
Interscholastic Sports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid as any other Injury
Bone Marrow Donation Testing, Benefits include Covered Medical Expenses for human leukocyte antigen testing performed
in a facility accredited by American Association of Blood Banks or the College of American Pathologists or other nationalaccrediting body with regulations equivalent to the College of American Pathologists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC Eating Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paid as any other Sickness
Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . URC
Urgent Care Clinic Fee, Benefits are limited to the Urgent Care Clinic fee billed by the Urgent Care Clinic/Hospital.
All other services rendered during the visit are payable as specified in the Schedule of Benefits. . . . . . . . . . . . . . . . . . . . . . . URC ELIGIBILITY
All Domestic Students registered for credit courses are eligible to enroll in this insurance plan.
All International Students registered for credit courses are automatically enrolled in this insurance plan at registration, unless proof of com-
parable coverage is furnished.
Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased. The Company maintainsits right to investigate student status and attendance records to verify that the policy Eligibility requirements have been met. If the Companydiscovers the Eligibility requirements have not been met, its only obligation to to refund premium. Medical withdrawal from school due to a cov-ered Injury or Sickness which originates after the Insured’s Effective Date will not void an Insured’s coverage.
EFFECTIVE AND TERMINATION DATES
The Master Policy on file at the school becomes effective at 12:01 a.m., September 1, 2013. The individual student’s coverage becomes effec-tive on the first day of the period for which premium is paid or the date the enrollment form and full premium are received by the Company (orits authorized representative), whichever is later. The Academic Year coverage terminates on 6/1/14. The Master Policy terminates at 11:59p.m., 8/31/14. Coverage terminates on that date or at the end of the period through which premium is paid, whichever is earlier.
The Summer School Master Policy on file at the school becomes effective at 12:01 A.M. June 15, 2013. The Individual student’s coveragebecomes effective on the first day of the period for which premium is paid of the date the enrollment form and full premium are received by thecompany (or its authorized representative), whichever is later. The summer school coverage terminates on 8/31/13. The Master Policy termi-nates at 11:59 P.M. 8/31/13. Coverage terminates on that date or at the end of the period through which premium is paid, whichever is earli-er.
Refunds of premiums are allowed only upon entry into the armed forces.
The Policy is a Non-renewable One Year Term Policy.
EXTENSION OF BENEFITS AFTER TERMINATION
The coverage provided under the master policy ceases on the Termination Date. However, if an Insured is Totally Disabled on the TerminationDate from a covered Injury or Sickness for which benefits were paid before the Termination Date, Covered Medical Expenses for such Injuryor Sickness will 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 will never exceed theMaximum Benefit.
After this “Extension of Benefits” provision has been exhausted, all benefits cease to exist, and under no circumstances will further paymentsbe made.
MANDATED BENEFITS
Biologically Based Mental Illness
Benefits will be paid the same as any other Sickness for the treatment of Biologically Based Mental Illness. The benefit provided will not dupli-cate any other benefits provided in this policy.
“Biologically Based Mental Illness” means schizophrenia and other psychotic disorders, schizoaffective disorder, bipolar affective disorder,major depressive disorder, obsessive-compulsive disorder, panic disorder, pervasive developmental disorder or autism, chronic post-traumat-ic stress disorder, and anorexia nervosa and bulimia nervosa.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any other provision of the policy.
ADDITIONAL BENEFITS
Benefits are provided as mandated by the State of New Hampshire for benefits, such as Benefits for Mammography, Benefits forReconstructive Breast Surgery, Benefits for Bone Marrow Transplants for Treatment of Breast Cancer, Benefits for Non-prescription EnteralFormula, Benefits for Outpatient Contraceptive Services, Benefits for Off-Label Prescription Drugs, Benefits for Clinical Trials, Benefits forDiabetes Treatment, Benefits for Medical or Hospital Dental Procedures, Benefits for Scalp Hair Prostheses, and Benefits for ProstheticDevices. A detail of these benefits may be found in the Master Policy on file at the school.
DEFINITIONS
Covered expenses means charges:
a. Not in excess of usual, reasonable and customary charge;
b. Not in excess of the maximum benefit amount payable per service as shown in the Schedule; c. Made for medical services and supplies not excluded under this Certificate; exclusion and limitations as shown in this brochure; d. Made for services and supplies which are medically necessary; and
e. Made for medical services specifically included in the Schedule.
Doctor means a licensed practitioner of the healing arts acting within the scope of his license. Doctor does not include:
b. A Covered Person’s spouse, dependent, parent, brother, or sister; or
c. A person who ordinarily resides with a Covered Person.
Injury means bodily harm resulting, directly and independently of disease or bodily infirmity, from an accident. All injuries to the same person
sustained in one accident, including all related conditions and recurring symptoms of injuries will be considered one injury.
Medically necessary means those services or supplies provided or prescribed by a hospital or doctor:
a. Essential for the symptoms and diagnosis or treatment of the sickness or injury;
b. Provided for the diagnosis, or the direct care and treatment of the sickness or injury;
c. In accordance with the standards of good medical practice; d. Not primarily for a Covered Person’s convenience or that of their doctor; and
e. That are the most appropriate supply or level of service that can safely be provided.
Sickness means illness or disease which first manifests itself or is diagnosed during the term of coverage for the covered person. Sickness
includes complications of pregnancy. All related conditions and recurring symptoms of the same or a similar condition will be considered the
same sickness.
Usual, reasonable and customary means:
a. Charges and fees for medical services or supplies that are the lesser of: 1. The usual charge by the provider for the services or supply given; or 2. The average charges for the service or supply in the area where service or supply is received; and b. Treatment and medical service that is reasonable in relationship to the service or supply given and the severity of the condition.
EXCLUSION 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 relat-ed to: Circumcision, unless a Medical Necessity; Congenital conditions, except as specifically provided for Newborn or adopted Infants or a covered Dependent Child which has resultedin a functional defect; Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy orfor newborn children; Dental treatment, except for accidental Injury to Sound, Natural Teeth; eye examinations, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or othertreatment for visual defects and problems; except when due to a disease process; Foot care including: care of corns, bunions (except capsular or bone surgery), calluses; Hearing examinations or hearing aids; or other treatment for hearing defects and problems. “Hearing defects” means any physical defectof the ear which does or can impair normal hearing, apart from the disease process; Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of acovered Injury, or as specifically provided in the policy; Injury caused by, contributed to, or resulting from the use of intoxicants, hallucinogenics, illegal drugs, or any drugs or medicines thatare not taken in the recommended dosage or for the purpose prescribed by the Insured Person’s Physician; Injury of Sickness for which benefits are paid or payable under any Workers’ Compensation or Occupational Disease Law or Act, or sim-ilar legislation; Injury sustained by reason of a motor vehicle accident to the extent that benefits are paid or payable by any other valid and collectibleinsurance; Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting; Prescription Drug Services, services or supplies as follows: a) Therapeutic devices or appliances, including hypodermic needles and syringes, except as specifically provided in the Benefits for Diabetes Treatment, support garments and other non-medical substances, regardless of intended use; b) Immunization agents, biological sera, blood or blood products administered on an outpatient basis; c) Drugs labeled, “Caution-limited by federal law to investigational use” or experimental drugs; except as specifically provided in the pol- e) Drugs used to treat or cure baldness, and anabolic steroids used for body building; f) Anorectics - drugs used for the purpose of weight control; g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; i) refills in excess of the number specified or dispensed after one (1) year of date of the prescription.
Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any serv-ices or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or oth-erwise; tubal ligation; vasectomy, sexual reassignment surgery; Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48 hours for vaginal delivery or 96 hours forcesarean delivery; Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injuryor Sickness; except as specifically provided in the master policy; Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the studentheath fee; Suicide or attempted suicide while sane or insane (including drug overdose); or intentionally self-inflicted Injury; Supplies, except as specifically provided in the master policy; Surgical breast reduction, unless a Medical Necessity, breast augmentation, breast implants or breast prosthetic devices or gynecomas-tia; except as specifically provided in the master policy; Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; 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 for suchperiod not covered when the Company is notified of the Insured’s entry into the armed services of any country); and Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat.
TRAVEL ASSISTANCE SERVICES
The Travel Assist Plan is designed to provide students who travel 100 miles or more from their home (or in a foreign country that is not thecountry of permanent residence), with worldwide, 24-hour, emergency assistance services during the term of coverage under the student acci-dent and sickness plan. The assistance services are provided by On Call International.
Emergency Medical Transportation Services are provided up to a combined maximum limit of $50,000 for covered services. Key servicesinclude: Emergency Evacuation, Medically Necessary Repatriation, Repatriation of Remains, Family of Friend Transportation Arrangementsand Return of Minor Children. All transportation related services, coverage and payments must be arranged and pre-approved by On CallInternational.
Worldwide emergency medical, legal and travel assistance services are available 24 hours a day, 365 days a year. For Assistance call: CLAIM PROCEDURE
In the event of Injury or Sickness, students should: 1) Report at once to the Student Health Service or Infirmary for treatment or referral, or when not in school, their nearest Physician or 2) Secure a Company claim form from the Student Health Service or from the address below, fill out the form completely, attach all medical and hospital bills and mail to the address below; 3) File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 90 days of service.
Failure to furnish such proof within the time required shall not invalidate nor reduce any claims if it shall be shown not to have been rea-sonably possible.
NOTE All Other inquiries Are to be Directed to:

Source: http://www.newhampton.org/ftpimages/97/download/UnitedStatesInsurance.pdf