TU Accident & Sickness Plan

Description of Benefits

BASIC ACCIDENT MEDICAL EXPENSE

Inpatient and Outpatient

When an Injury requires A) treatment by a Doctor/Surgeon; B) hospital confinement; C) services of a licensed nurse practitioner or RN; D) x-ray services E) Use of an operating room, anesthesia, laboratory services; F) prescribed medicines, plaster casts, surgical dressings; or G) use of an ambulance, we will pay, after a $25.00 deductible per Injury, the UCR charges incurred up to a maximum of $1,000.00 per Injury, within 52 weeks from the date of injury.

Accidental Dental Expense: We will pay the UCR charges incurred for dental treatment as a result of accidental Injury to sound natural teeth up to a maximum of $250.00 per tooth.

BASIC SICKNESS MEDICAL EXPENSE

If as the result of a Sickness, a Covered Person incurs medically necessary medical expenses, we will pay, after a $25.00 deductible per sickness, the UCR charges that incurred within 52 weeks from the date of the Sickness or commencement of the first expense up to a maximum of $1,000.00 per Sickness.

Hospital Room and Board Expense: If a Covered Person requires confinement in a hospital, we will pay the UCR charges incurred for the semi-private room rate up to a maximum of $250.00 per day .

Hospital Miscellaneous Expenses: If a Covered Person incurs expenses during a hospital confinement or day surgery on an outpatient basis for: anesthesia; operating room; laboratory test; x-rays; oxygen tent; drugs; medicines; dressings; and other necessary non-room and board expenses; we will pay the UCR charges incurred up to a maximum of $800.00 per sickness.

Surgical Expense: We will pay the UCR charges incurred up to a maximum of $500.00 per Sickness for the surgery performed by a physician (in or out of hospital). Benefits will be paid in accordance with the Medical Data Research schedule for UCR charges.

In Hospital Physician Visits Expense: If a Covered Person requires the non-surgical services of a physician while confined to a hospital, we will pay the UCR charges incurred up to a maximum of $30.00 per visit, limited to one visit per day.

Outpatient Physician Office Visit Expense or Physical Therapy: When, as a result of Sickness, a Covered Person requires the services of a physician, we will pay the UCR expense up to a maximum of 3 visits. If a referral is not obtained from the Student Health Center, there will be no benefits paid under this plan. (See also “When a referral from the Student Health Center is not necessary”).

Outpatient Diagnostic X-ray and Laboratory Expense: If a Covered Person requires diagnostic x-ray and laboratory procedures when prescribed by a doctor and performed at the Student Health Center or referred by the Student Health Center, we will pay the UCR charges incurred up to a maximum of $200.00 per Sickness. If a referral is not obtained from the Student Health Center, there will be no benefits payable under this plan. (See also, “When a Student Health Center referral for outside care is not necessary”).

Health Center Exoense: We will pay 60% of covered charges for certain medications, tests, and medical supplies provided by the Student Helath Center to a Covered Person.

When a Student Health Center referral for outside care is not necessary:

Emergency Care: the insured student or dependent must return to the Student Health Center for necessary follow-up care;

When the Student Health Center is closed;

When service is rendered at another facility during break or vacation periods;

Medical care received when the insured student is more than 50 miles from the campus;

Medical care obtained when an insured student is no longer able to use the Student Health Center due to change in student status.

Emergency Room: If a Covered Person requires the use of the emergency room for Emergency Care, we will pay 80% of the UCR charge expense incurred up to a maximum of $500.00 per Sickness. (Including the cost of laboratory services and x-rays).

Outpatient Prescription Drug Coverage: If a Covered Person requires outpatient prescription drugs prescribed by a physician and associated with a covered Sickness, we will pay the expense incurred up to the maximum of $50.00 per Sickness. Medications not covered by this benefit include, but are not limited to: asthma & allergy medications (i.e. inhalers), diabetic supplies including insulin and syringes, birth control pills, topical acne treatments (i.e. Retin-A) and any medication prescribed for any pre-existing condition.

Ambulance Expenses: When, by reason of a covered Injury or Sickness, a Covered Person requires the use of a ground or air ambulance, we will pay the UCR charges up to the maximum of $250.00 per sickness.

Sickness Dental Expense: We will pay the UCR charge expense incurred up to a maximum of $100.00 per tooth and an aggregate maximum of $200.00 for surgical removal of impacted wisdom teeth and dental abscesses.

In Addition , the company will pay for one mammogram every year for women.

SUPPLEMENTAL ACCIDENT AND SICKNESS EXPENSE

If the covered medical expenses paid for a covered Injury or Sickness exceed $1,000.00 per covered Injury or Sickness under the Basic Accident or Basic Sickness Medical Expense Benefits, we will pay 80% of the medically necessary UCR charges expense incurred, in excess of $1,000.00 per covered Injury of Sickness, up to an aggregate maximum or $25,000.00 per covered Injury or Sickness. Benefits under the Supplemental Accident and Sickness Medical Expense, or until the payment of the aggregate maximum, whichever occurs first. This benefit does not include any payment for expenses incurred for the Sickness Dental Expense or the Accidental Dental Expense.

Mental and Nervous Conditions Expense

Inpatient: If any Covered Person requires treatment for Mental and Nervous disorders during hospital confinement, we will pay the UCR expense incurred on the same basis as any other Sickness up to a maximum of $2,000.00 per policy year.

Outpatient: When the Covered Person is not hospital confined, we will pay the UCR charge expense incurred for outpatient services, up to a maximum of $500.00 per policy year.

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT

If loss occurs within 90 days from the date of accident, the plan will pay, in addition to medical treatment benefits one of the following amounts, If more than one stated loss is sustained as a result of one, accident only one of the following amounts is payable (the largest applicable amount):

Accidental Death: $10,000.00

Accidental Loss of:

Both hands, or feet or eyes $10,000.00

One hand and one foot $10,000.00

Hand or foot and one eye $10,000.00

Either hand or foot or one eye $5,000.00

Loss in regard to hand or hands, or foot or feet, shall mean actual severance through or above wrist(s) or ankle(s), and loss of sight of eyes shall mean the irrecoverable loss of entire sight.

Only one of the amounts named above will be paid for injuries resulting from any one accident. The amount so paid shall be the largest amount that applies.

This provision does not cover the loss if it in any way results from or is caused or contributed:

By physical or mental illness; medical or surgical treatment except treatment that results from a surgical operation made necessary solely by an injury covered by this plan.

By an infection, unless caused solely and independently by a covered accident.

While committing or trying to commit a crime.

While the insured person is intoxicated or under the influence of any drug unless taken as prescribed by a physician.

In addition to the above, this provision is subject to the Exclusions and Limitations of this plan.

EMERGENCY MEDICAL EVACUATION & REPATRIATION

Medical Evacuation: In the event a Covered Person requires treatment as a result of a covered Injury or Sickness and the appropriate medical facility can no longer provide the Medically Necessary treatment, the Covered Person will be evacuated to the nearest appropriate medical facility. Expenses for evacuation, accompanying physician or nurses, services or supplies which are directly medically necessary for the evacuation and fees necessary to arrange for the evacuation, are covered up to $10,000.00. The expenses with respect to the medical evacuation require prior approval

OTHER INSURANCE

All benefits provided under this plan are payable in excess of any other valid and collectible insurance that is in force as to a Covered Person. Any charges in excess of the limits of the other insurance are covered subject to the conditions and limitations of the Student Accident and Sickness Insurance Plan.

Exclusions

Except as otherwise indicated, benefits are not payable under this plan for any of the following or loss that results therefrom:

Treatment, services, or supplies provided by the school’s infirmary or its employees, or physicians who work for the school, except as previously stated herein.
Eye examinations; prescriptions or fitting of eyeglasses and contact lenses; or other treatment for visual defects and problems, except as required as a result of a covered injury. “Visual defects” means any physical defect of the eye that does or can impair normal vision.
Hearing examinations or hearing aids; or other treatment for hearing defects and problems. “Hearing defects” means any physical defect of the ear that does or can impair normal hearing.
Participation in a riot or civil disorder; fighting or brawling except in self-defense; commission of or attempt to commit a felony.
Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planning, bungee jumping, or flight in any type of aircraft, except while riding as a fare-paying passenger on a regularly-scheduled airline
War or any act of war, declared or undeclared; or while serving in the armed forces of any country (a pro-rata premium will be refunded for such a period of service.)
Injury or sickness covered by worker’s compensation or employer’s liability laws, or by any coverage provided or required by law (including, but not limited to group , group type, and individual automobile “no-fault” coverage).
Treatment, services or supplies provided by a hospital or facility owned or run by the United States Government, unless a charge is made for such services in the absence of insurance; or in a hospital which does not unconditionally require payment.
Elective treatments and voluntary testing.
Cosmetic surgery, except cosmetic surgery which the covered person needs as the result of an accident congenital disease or abnormality of a covered newborn dependent child which has resulted in a functional defect.
Expenses for treatment of injuries sustained as a result of a motor vehicle accident to the extent that benefits are payable under other valid and collectible insurance whether or not a claim is made for such benefits.
Treatment of drug addiction or alcoholism.
For international student only, expenses incurred within the covered person’s home country or country of regular domicile.
Routine physical examinations and routine testing; preventive testing or treatment; screening examinations or testing in the absence of Injury or Sickness.
Birth control, including surgical procedures and devices.
Pre-existing conditions subject to any applicable credit for prior coverage.
Treatment that is not incurred by an insured person while insured hereunder.
Suicide attempted suicide or intentionally self-inflicted injury while sane or insane.
Injury, sickness, or death contributed to by the use of drugs or alcohol, unless administered by a physician.
Participation in, practice for, or orthopedic equipment and appliances used for intercollegiate sports, including intercollegiate club sports.