CONFORMITY WITH STATE STATUTES Any provision of this plan of insurance which, on its effective date, is in conflict with the statutes of the state in which it is issued, is hereby amended to conform to the minimum requirements of such statutes. EXCLUSIONS AND LIMITATIONS 1. Treatment, services or supplies which: · Are not Medically Necessary; · Are not prescribed by a Doctor as necessary to treat an Injury; · Are determined to be Experimental/Investigational in nature; · Are received without charge or legal obligation to pay; · Are received from persons employed or retained by the Policyholder or any Family Member, unless otherwise specified; or · Are not specifically listed as Covered Charges in this Policy. 2. Intentionally self-inflicted Injury, violating or attempting to violate any duly enacted law. Injury by acts of war, whether declared or not. War means an interruption of all relations between nations and an authorized contestation of armed forces by the constitutional authority of the nations. War does not include acts of terrorism. 3. Injury received while traveling or flying by air, except as a fare-paying passenger on a regularly scheduled commercial airline. 4. Services or supplies for the treatment of an Occupational Injury which are paid under the North Carolina Workers’ Compensation Act only to the extent such services or supplies are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ Compensation Act. 5. Injury contributed to by the use of alcohol or drugs not prescribed by a Doctor. 6. Fighting, except as an innocent victim. 7. Heart and/or circulatory malfunction resulting from participation in a Covered Activity. 8. Repetitive motion Injuries, strains, hernia, tendinitis, bursitis and heat exhaustion not related to a specific Injury. 9. Dental treatment, except as specifically stated. 10.Eyeglasses, contact lenses, routine eye exams or prescriptions therefore. 11. Injury sustained while committing or attempting to commit a felony. 12.Loss resulting from being legally intoxicated or under the influence of alcohol as defined by the laws of the state in which the Injury occurs. 13.Suicide or attempted suicide while sane or insane. 14.Injury sustained while operating, riding in or upon, mounting or alighting from, any two- or three- or fourwheeled recreational motor/engine driven vehicle or snowmobile or all terrain vehicle (ATV). 15.Injury sustained scuba diving, surfing, roller skating, skateboarding or rodeo. 16.Injury sustained while participating in or practicing for any professional, intercollegiate or club sports activity, except as specifically provided. CLAIM PROCEDURE The Insured Person should: 1.Obtain a claim form from the Student Wellness Center, or by contacting the claim administrator, Administrative Concepts, Inc. (ACI). 2.Complete a claim form and mail it to ACI within 60 days of the date of the Injury or commencement of the Sick ness, or as soon thereafter as possible. Mail the claim form to Administrative Concepts, Inc., 994 Old Eagle School Road, Suite 1005, Wayne, PA 19087-1802. 3. Claim forms are available online at www.visit-aci.com or by calling 888-293-9229. If the providers have given you bills, attach them to the claim form. 4. Direct all questions regarding benefits available under this Plan, claim procedures, status of a submitted claim or payment of a claim to ACI. Online claim status is available at www.visit-aci.com or by calling 888-293 9229. Select option “2” for Customer Service. 5. Itemized medical bills must be attached to the claim form at the time of submission. Subsequent medical bills received after the initial claim form has been submitted should be mailed promptly to ACI. No additional claim forms are needed as long as the Insured Person’s name and identification number are included on the bill. 6. The physicians and hospitals may submit itemized bills directly to ACI electronically using Payor # 22384 or mailing them to ACI. PREFERRED PROVIDER INFORMATION By enrolling on the Student Health Insurance Plan you have access to the My First Health Preferred Provider Network. Please read the following information so you will know from whom or what group of provider’s health care may be obtained. This enhancement to your program does not require you to use a Preferred Provider. You may receive care from any license provider (benefit eligibility is subject to the plan design and the exclusions and limitations as specified in the policy), but if you incur any expense using a Preferred Provider you may lower your out-of-pocket expense. You may check for My First Health Preferred Providers by calling 1-800-226-5116 or visiting www.myfirsthealth.com. APPEALS PROCEDURE If Your claim is denied You will be notified of the reason with a description of any additional information necessary to appeal the denial. If You or Your provider would like additional information or have a complaint concerning the denial, please contact the Insurer’s Third Party Administrator, Administrative Concepts, Inc. (ACI) at 888-293-9229. ACI will address concerns and attempt to resolve the complaint. If ACI is unable to resolve the complaint over the phone, You may file a written internal appeal by writing to ACI. Please include Your name, home address, policy number, and any other information or documentation to support the appeal. The appeal must be submitted within 60 days of the event that resulted in the complaint. ACI will acknowledge Your appeal within 10 working days of receipt or within 72 hours if the appeal involves a life-threatening situation. A decision will be sent to You within 30 days. If there are extraordinary circumstances involved, ACI may take up to an additional 60 days before rendering a decision. Underwritten By: Guarantee Trust Life Insurance Company Glenview, IL Plan Administered By: First Agency, Inc. 5071 West H Avenue Kalamazoo, MI 49009-8501 Ph. (269) 381-6630 www.1stAgency.com Claims Servicing Address: Administrative Concepts, Inc. 994 Old Eagle School Rd. Suite 1005 Wayne, PA 19087-1802 Ph. (888) 293-9229 www.visit-aci.com Local Servicing Provided By: HVWM/Bankers Insurance P.O. Box 20, Asheville, North Carolina 28802 Ph. (828) 253-2371 NOTE Keep this brochure as a summary of the Insurance. No individual Policies will be sent. If any discrepancies exist between the brochure and the Policy, the Policy on file with the College governs the payment. STUDENT ACCIDENT AND SUPPLEMENTAL SICKNESS INDEMNITY PLAN Coverage Effective 8/1/13 - 8/1/14 2013-2014 Policy No. 324-120-012-R Policy #324-120-012-R Dear Students, Parents and Guardians: In an effort to provide the best possible health care to our students, Belmont Abbey College is making available a Blanket Accident and Supplemental Sickness Indemnity Policy for its students. Please take a few minutes to review the following information. All full-time day-program students attending Belmont Abbey College are automatically enrolled in the Accident and Supplemental Sickness Indemnity plan. To be exempt from this coverage and fee, you are required to show proof of other medical insurance. The waiver form must be completed online at the following link: http://1stagency.com/forms/waiver_belmontabbey.php no later than September 21, 2013 (February 14, 2014 for Spring Term enrollees).If the waiver is not received by those dates, the fee will remain on your bill. The cost for students entering the Fall Term is $363.00, for the Spring Term $254.00. If your personal insurance is an HMO. We urge you to seriously consider enrolling in the school-sponsored plan. Many HMO’s will only pay for treatment outside their network area when it is an emergency and will not pay for treatment from doctors out of their area without prior permission, sometimes not even then. This Plan protects insured students on and off campus, at home or while traveling. This Plan is primary to any other insurance the student may carry. Sincerely, The Business Office Belmont Abbey College ELIGIBILITY All full-time day-program students enrolled for a minimum of 12 credit hours are included in this insurance plan and the premium for coverage is added to your bill unless proof of comparable coverage is furnished. Part-time day-program students enrolled for a minimum of 6 credit hours may purchase this insurance plan. Please contact the business office for payment details. REFUND PROVISION The Company retains the right to investigate student status and attendance records to verify that Policy eligibility requirements have been met. If the Company discovers that the Policy eligibility requirements have not been met, the Company’s only obligation is refund of premium. Eligibility requirements must be met each time a premium is paid to continue coverage. TERM OF COVERAGE The Coverage term for the current school year becomes effective on 8/1/13 (for Spring Term enrollees 1/1/14) at 12:01 a.m. and terminates on 8/1/14 at 12:01 a.m. Exceptions will be made for the following: 1. Enrolling as a new or transfer student within 31 days of enrollment at the school. 2. Within 31 days of ineligibility under another plan of Creditable Coverage and accepted and exhausted COBRA continuation of coverage if offered. Coverage terminates at the earliest of: • the termination of the Policy; • the last day of the Term of Coverage for which premium is paid; • the date the insured ceases to be an eligible person. Coverage remains in effect during holiday and vacation periods. Should an Insured Person graduate or withdraw from the college, the insurance shall remain in effect until the end of the period for which premium has been paid. WAIVER DEADLINE If You have proof of comparable insurance and wish to waive coverage, the deadline to waive out of this plan is 9/21/13. For students beginning their studies in the spring, the deadline is 2/14/14. DEFINITIONS Accident: A sudden unforeseeable external event which results in an Injury. Covered Charge: A service or supply listed in the certificate and which is performed or given for the treatment of an Injury. Injury: Bodily injury due to an Accident which, results directly and independently of disease, bodily infirmity or any other causes; solely, directly and independently of all other causes results in medical expense; occurs after the effective date of coverage under the Certificate; and occurs while the Certificate is in force. All injuries sustained in any one Accident, including all related conditions and recurrent symptoms of these Injuries, are considered a single Injury. Injury includes Complications of Pregnancy related to an Accident. Pre-existing Condition: A condition for which medical care, treatment, diagnosis or advice was received or recommended within the 12 months prior to the Effective Date of coverage under the Certificate. Reasonable and Customary Charges, Fees or Expenses: The most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the area in which the charge is incurred, so long as those charges are reasonable. BASIC ACCIDENT MEDICAL EXPENSE BENEFIT Treatment of Injury must begin within 30 days of covered accident. (All amounts are on a per Injury basis, unless otherwise stated) Maximum Benefit Amount, per Injury $10,000 Automobile Accident Maximum Benefit Amount $500 Deductible, per Injury $0 Insured Percentage 100% of R&C* Benefit Period 52 weeks Covered Services Treatment by a qualified Doctor or surgeon; Hospital and nursing services; Miscellaneous Hospital expense such as drugs, medicines, x-rays and operating room; Ambulance services; and Dental treatment to sound, natural teeth up to $200/per tooth. *R&C = Reasonable & Customary ADDITIONAL ACCIDENT MEDICAL EXPENSE BENEFIT Maximum Benefit Amount, per Injury $5,000 Insured Percentage 80% of R&C* This benefit applies when a student’s incurred covered charges are more than $10,000. The maximum benefit paid under the Basic Accident and Additional Accident Medical Expense Benefit will never be more than $15,000. SUPPLEMENTAL SICKNESS INDEMNITY BENEFIT Maximum Benefit Amount, per Sickness** $10,000 Deductible $0 Covered Charges: - Outpatient Miscellaneous Hospital Expense, such as, but not limited to laboratory tests, x-rays, and MRIs. R&C* - Outpatient Doctor’s Fees, including surgeon’s fees and anesthesiologist R&C* - Outpatient Hospital Emergency Care, including use of ER room and supplies and Imaging procedures and laboratory tests performed while patient is an emergency room patient R&C* **Sickness means illness or disease; routine and preventive services are not covered under this benefit. *R&C = Reasonable & Customary OTHER BENEFITS Medical Evacuation Up to $10,000 Repatriation Up to $7,500 This is a summary of coverage. It does not contain all provisions, limitations and exclusions.
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