Student Accident and Sickness Insurance Plan 2013/2014

Student Insurance Plan 2013/2014

This outline of coverage contains the essential provisions of the Plan and should be retained for reference because no Individual certificate will be issued. The Master Policy is maintained by the College.

Policy No. 2013B1A05

The following describes the Student Accident and Sickness Insurance Plan. This Student Health Insurance Plan is designed to provide protection against the expense of accident and sickness 24 hours a day, both at college and when away from campus.

ELIGIBILITY AND COST

All full-time students attending Bethel College are eligible for coverage under the Student Accident and Sickness Insurance Plan. The premium per student for the Fall Term beginning August 1, 2013 and ending August 1, 2014 is $1,308 and is payable along with your student fees at the beginning of the Fall Term. If you do not desire to purchase this coverage, you must go online to the Bethel website, login to my BC, and complete the insurance waiver by no later than September 15, 2013. If the college does not receive this waiver form by the time indicated above, you will be automatically enrolled in the Plan. Spouses and children are also eligible and, although not automatically covered, may apply for the Insurance through the Student Development Office.

COVERAGE

This Plan, subject to the benefits and exclusions outlined in the brochure, protects the Insured Student of Bethel College and his or her insured dependents at home, at school, or while traveling—24 hours a day—anywhere in the world, during the term of the Policy.

In the event a Student ceases to be a Student at the College, coverage remains in effect until the end of the period for which premium has been paid. Upon any Insured entering the armed forces of any country, coverage will automatically terminate, and a pro-rata refund of premium will be made upon request. No other refunds will be made.
Protection is in effect during all interim vacation periods.

GENERAL PROVISIONS

The policy is underwritten by National Guardian Life Insurance Company, Madison, Wisconsin and the Representative is Wells Fargo Insurance Services, P.O. Box 276, Columbus, OH 43516-0276. All claims will be paid by Special Risk Claims, Commercial Travelers Mutual Insurance Company, 70 Genesee St., Utica, NY 13502.

NOTICE: If an insured person is covered by more than one health care plan, he or she may not be able to collect benefits from both plans. Each plan may require an insured to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. An insured should read all of the rules very carefully, including the coordination of benefits section and compare them with the rules of any other plan that covers an insured or his/her family.

BASIC PLAN BENEFITS

Benefits
Deductible	$100 per policy year
Benefit Period:	Policy Term
Aggregate Medical Maximum:	$500,000 per policy year
Usual & Customary Fees:	Pays 80%
Inpatient Benefits
Room and Board Expense	80% U&C
Intensive Care	80% U&C
Hospital Miscellaneous Expenses	80% U&C
Preadmission Testing	80% U&C
Physical Therapy	80% U&C
Surgery	80% U&C
Anesthetist Services	80% U&C
Assistant Surgeon	80% U&C
Registered Nurse’s Services	80% U&C
Physician’s Visits	80% U&C
Mental and Nervous Disorders	80% U&C
Outpatient Benefits
Surgery	80% U&C
Anesthetist Services	80% U&C
Assistant Surgeon	80% U&C
Outpatient Surgery Miscellaneous	80% U&C
Physician’s Visits	80% U&C
Medical Emergency Expenses	80% U&C
Diagnostic X-ray Services	80% U&C
Laboratory Procedures	80% U&C
Prescription Drugs	80% U&C
Mental and Nervous Disorders	80% U&C
Other Benefits
Ambulance Service	80% U&C
Maternity Benefit	80% U&C
Routine Newborn Care	80% U&C
Consultant Physician Services	80% U&C
Intercollegiate Sports	80% U&C up to $1,000
Preventative Services (Not subject to deductible)	100% U&C

ALTERNATIVE COVERAGES

Medical • Dental • Vision • Prescription Drugs

If you do not meet the eligibility requirements of this plan and need additional coverage, or if you are looking for optional coverage for Dental, Vision, or Prescription Drugs, please call Wells Fargo Insurance Services at: 1-800-228-6768 or visit our website at: wfis.wellsfargo.com/colleges for information on alternative insurance plans.

CLAIM PROCEDURE

In the event of accident or sickness, the Student should:

If at the School, report immediately to Student Health Services so that proper treatment can be prescribed or approved.
If away from the School, consult a doctor and follow his/her advice. Notify Student Health Services or the Claims Administrator within 30 days after the date of the covered accident or commencement of the covered illness, or as soon thereafter as is reasonably possible.

Claims forms and instructions on claim procedures are available at the College Student Health Services or by visiting the website at: www.studentplanscenter.com or Companion Claim Form.

Written notice of injury or sickness, upon which claim may be based, must be provided to the Company within 30 days of the date of the commencement of the first loss for which benefits arising out of each injury or sickness may be claimed, or as soon thereafter as is reasonably possible. Bills for which benefit is to be paid must be submitted within 90 days of the treatment.

GRIEVANCE AND APPEALS

If an insured person has a grievance or is appealing a grievance decision, contact The Claims Administrator either orally or in writing: Commercial Travelers Mutual Insurance Company, 70 Genesee St., Utica, NY 13502. Toll free: 800-756-3702

Notice to insured: Upon the Insured Person’s notice of a grievance, we or our agent shall provide timely, adequate, and appropriate notice to each insured of: 1) the grievance procedure required under Indiana law; 2) the external grievance procedure required under Indiana law; 3) information on how to file a grievance and a request for an external grievance review permitted under Indiana law; and 4) a toll free telephone number through which an Insured Person may contact us at no cost to the Insured Person to obtain information and to file grievances.

HOW TO FILE AN APPEAL

Once a claim is processed and upon receipt of an Explanation of Benefits (EOB), an insured student who disagrees with how a claim was processed may appeal that decision. The student must request an appeal in writing within 60 days of the date appearing on the EOB. The appeal request must include why they disagree with the way the claim was processed. The request must include any additional information they feel supports their request for appeal, e.g. medical records, etc. Please submit all appeal requests to the Claims Administrator.

Protecting Health Information
Commercial Travelers Insurance Company is committed to guarding the protected health insurance information of those we insure. In the course of conducting our business, we create and maintain the confidentiality of protected health information as required by the Health Insurance Portability and Accountability Act of 1996 (HIPPA), and we will follow the terms of our Notice of Privacy Practices. A copy of this Notice is available from the College Business Office or on our website at www.commercialtravelers.com/privacy.html.

Underwritten & Claims Administered by
Commercial Travelers Mutual Insurance Company
70 Genesee Street • Utica, New York 13502
as policy form # CTBH-280 (Rev. 04) (IN)
800-756-3702
www.studentplancenter.com
as Policy Form # CTBH-280 (Rev. 04) (IN)
For a copy of the Company’s Privacy Notice, go
to: www.commercialtravelers.com/privacy.html
or
Request one from the Health office at your school
or
Request one from:
Commercial Travelers Mutual Life Insurance Company
c/o Privacy Officer
70 Genesee Street • Utica, New York 13502
(Please indicate the school you attend with your written request.)
Representative
Wells Fargo Insurance Services • P.O. Box 276
Columbus, Ohio 43216-0276
800-228-6768 • wfis.wellsfargo.com/colleges

NETWORK PROVIDER
MultiPlan • www.multiplan.com
800-672-2140
Representations of this plan must be approved by the Company.

This is not the Policy. Rather it is a brief description of the benefits and other provisions of the Policy. The Policy is governed by the laws and regulations of the state in which it is issued. Any provisions of the Policy, as described above, that may be in conflict with the laws of the state where the school is located will be administered to conform with the requirements of that state’s laws, including those relating to mandated benefits.

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

IMPORTANT
This outline of coverage is intended only for quick reference and does not limit or amplify the coverage as described in the master policy which contains complete terms and provisions. A copy of the master policy is on file at the school.

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