MedicineLakex

 

Summerscholars.lawrenceville.org

2015–2016
International Student
Injury and Sickness Insurance Plan for
Lawrenceville Summer Scholars
Available through Global Travelers Organization, Limited.
Eligibility
All international students attending a private secondary school registered for credit courses are eligible and must be enrolled in the plan on a
hard waiver basis. U.S citizens are not eligible for coverage.
Effective and Termination Dates
This Insurance Plan becomes effective at 12:01 am on July 24, 2016
This Insurance Plan terminates at 11:59 pm on August 13, 2016

Highlights of the Coverage and Services offered by Student Resources (SPC) Ltd. Overall Plan Maximum
$500,000 Maximum Benefit (For each Injury or Sickness) Plan Deductible
100% of Usual and Customary Charges for Covered Medical Expenses All benefits are subject to specific benefit limitations, maximums and Copays as described in the plan brochure. Prescription Drugs
$0 Copay for Tier 1 $2,000 maximum (Per Policy Year) $0 Copay for Tier 2 No benefits outside of UnitedHealthcare Network $0 Copay for Tier 3 Pharmacy. Up to a 31-day supply per prescription filled at a UnitedHealthcare Pharmacy (UHCP) Outpatient Physiotherapy
100% of Usual and Customary Charges/$2,500 maximum Per Policy Year Surgeon's Fees
100% of Usual and Customary Charges 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. Assistant Surgeon
30% of Surgery Allowance Preventive Care Services
100% of Usual and Customary Charges Preventive Care Services which include, but are not limited to, annual physicals, GYN exams, routine screenings and immunizations. Preventive care limitations apply based on age and risk group factors. The following services are also included:
►Physician's Visits ►Interscholastic Sports Injuries This list is not all inclusive. Please read the plan ►Acne Treatment ►Hospital Room and Board brochure for complete listing of benefits and any ►Diabetes Services ►Out-Patient Lab and X-rays individual benefit maximums or limitations. ►Allergy Treatment ►Urgent Care Fees ►Medical Emergency ►Durable Medical Equipment ►In-Patient and Out-Patient Mental Illness Treatment ►Dental Treatment – Injury to Sound, Natural Teeth only International Students are covered worldwide except in their home country. This Plan is underwritten by Student Resources (SPC) Ltd. (A UnitedHealth Group Company) and is based on policy number 2015-202814-4. Where can I get more information about the benefits available?
The plan brochure provides more detail of the coverage including benefits, exclusions, any reductions or limitations and the terms under
which the coverage may be continued in force. Please contact the school for copies of the plan brochure.
14INDSB-202814-4 Student Resources (SPC) Ltd. Who can answer questions I have about the plan?
If you have questions please contact Customer Service at 1-888-455-9402
The Policy is a Non-Renewable One Year Term Policy. 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 any of the following:
Allergy testing; Addiction, such as: nicotine addiction, except as specifically provided in the policy; and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending, shopping, working and religious; codependency; Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn children; Dental treatment, except for accidental Injury to Sound, Natural Teeth; Elective Surgery or Elective Treatment; Elective abortion; 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; Routine foot care including the care, cutting and removal of corns, calluses, and bunions (except capsular or bone surgery); 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; Hirsutism; alopecia; Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury or as specifically provided in the policy; Injury caused by, contributed to, or resulting from the addiction to or use of alcohol, intoxicants, hallucinogenics, illegal 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; Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; Injury or Sickness inside the Insured's home country; Injury or Sickness when claims payment and/or coverage is prohibited by applicable law; Organ transplants; Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting; Prescription Drugs, services or supplies as follows; a. Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use, except as specifically provided in the policy; b. Immunization agents, except as specifically provided in the policy, 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; d. Products used for cosmetic purposes; e. Drugs used to treat or cure baldness; 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; h. Growth hormones; 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 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; 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; Preventive care services; routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specifically provided in the policy; Services provided normally without charge by the Health Service of the institution attended by the Insured; or services covered or provided by a student health fee; Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; 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; Sleep disorders; Supplies, except as specifically provided in the policy; Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; and 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). 14INDSB-202814-4 Student Resources (SPC) Ltd.

Source: http://summerscholars.lawrenceville.org/wp-content/uploads/2015/01/Summer-2016-GTO-Plan-Summary-ESF-Inc-Session-2.pdf