Student Accident and Sickness Insurance Plan 2012/2013

Student Insurance Plan 2012/2013

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

Policy No. 2012B1A05

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. New Students arriving on or after June 11, 2012 and attending classes prior to August 1, 2012 may enroll in the plan voluntarily by completing the enrollment form which can be found online at www.studentplanscenter.com. Go to Bethel College and click on forms. There you will find the Summer 2012 voluntary enrollment form. Complete the form and send it to Wells Fargo Insurance Services.The cost for the Summer Term is $225. Coverage begins on June 11, 2012 or the date following the postmark date on the envelope containing your payment whichever is later. Coverage will terminate August 1, 2012. Full-time students arriving beginning the Fall Term are eligible for and included in the Student Accident and Sickness Insurance Plan unless coverage has been specifically waived. The premium per student for the Fall Term beginning August 1, 2012 and ending August 1, 2013 is $645 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, 2012. 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 this 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.

Coverage for the Summer Term becomes effective at 12:01 a.m. on June 11, 2012 and continues for the period for which the premium has been paid. Coverage for the Fall Term becomes effective on August 1, 2012 and continues for the period for which the premium has been paid. The Master Policy expires at 12:01 a.m. on August 1, 2013.
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 Companion Life Insurance Company, Columbia, SC and the Representative is Wells Fargo Insurance Services, P.O. Box 276, Columbus, OH 43216-0276. 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

When hospital or medical care is required because of a covered accident or sickness, the usual and reasonable expense incurred will be paid by the Company as provided by the Policy. Following is a summary of the benefits payable for each covered accident or sickness.

ACCIDENT MEDICAl EXPENSE

For each covered accident occurring while the Insured’s coverage is in force, the Policy will pay up to $1,000. This will be used as necessary to pay for eligible usual and reasonable expenses such as treatment by a legally qualified physician or surgeon, hospital confinement, the services of a registered graduate nurse, X-ray service, use of operating room, anesthesia, laboratory service, surgical dressings, medicines, plaster casts, and use of wheelchair or crutches or ambulance. Treatment of injuries to natural teeth is included, not to exceed $100 for each accident. Treatment or service must be prescribed by a legally qualified physician or dentist and provided within 52 weeks from the date of the covered accident.

SICKNESS MEDICAL EXPENSE

When hospital or medical treatment is provided due to a covered sickness, the medical expenses incurred within 52 weeks from the date of the first treatment will be paid up to $1,000 per sickness, subject to the following provisions:

Hospital Room and Board, maximum of 30 days per any one (1) sickness—semi-private rate for first 3 days then $30 per day for the next 27 days.
Hospital Miscellaneous Expenses while confined in a hospital, including operating room, anesthesia, drugs, medicines, X-rays, oxygen tent, dressings and laboratory tests, each sickness up to a maximum of $300.
Surgery, inpatient or outpatient, up to a maximum of $400, based on usual and reasonable.
Physicians’ visits, up to $25 per visit (limited to one (1) visit per day) for visits to a patient confined in a hospital, to a maximum of $150.
Registered Nurse Service during a period of hospital confinement for which expense is payable under hospital room and board provision, $15 per day, maximum each sickness or $450.
Outpatient Miscellaneous Expense incurred as an outpatient for necessary medical treatment of a covered sickness to a maximum of $200.
Physician office visits are limited to $90 per visit to a maximum of three (3) visits for any one sickness and only when approved by Student Health Services.
Ambulance expense if, on account of such sickness, the Insured requires ambulance service to or from the hospital. The Company will pay the reasonable expenses incurred by or on behalf of the Insured for such service, not to exceed $300 for any such sickness.
Consultants’ fees when requested by the attending physician, to a maximum of $100 for any one (1) sickness.
Mental and Nervous disorder benefits will be paid on the same basis as any other covered sickness.

SUPPLEMENTAL MEDICAL EXPENSE

When as the result of a covered sickness or injury as defined, the insured requires treatment by a currently licensed physician or surgeon, hospital confinement, X-ray examination, surgical or medical supplies and services, use of an ambulance or the service of a licensed or graduate nurse, and the additional medical expenses incurred are in excess of the deductible, the Company will pay up to 80% of the usual and reasonable expenses incurred within 52 weeks of the date of accident or date of first treatment for such sickness. Since it is not intended that the student receive greater benefits than the actual expenses incurred, any other coverage will be taken into account in determining the amount of benefits payable under this portion of the Policy. See the Non-duplication provision for further details. The aggregate maximum medical expense payment under the Supplemental Medical Expense Benefits shall not exceed $25,000 as the result of any one (1) sickness or accident.

DEDUCTIBLE AMOUNT

Accident—$1,000 (paid under Basic Accident Medical Benefit)
Sickness—$200 in addition to the amount payable under the basic plan benefits.

TREATMENT OF SUBSTANCE ABUSE— OUTPATIENT

The Policy will pay for outpatient treatment of Substance Abuse for expense incurred for services legally performed by or under the clinical supervision of a physician or licensed psychologist, whether performed in a physician’s or psychologist’s office, in a hospital, in a community mental health facility, or in an alcoholism treatment facility, after a $25 deductible, 50% of expense incurred, to a maximum payment of $550.

MANDATED BENEFITS

The following benefits are mandated in the state of Indiana. They will be included in all plans issued under the Policy. Unless specified otherwise, all such coverage will be subject to any deductible, co-payment and co-insurance conditions of the Policy as well as all other terms and conditions applicable to any other covered sickness. Mandated benefits include, but are not limited to, Cancer Screening Tests; Mastectomy, Reconstructive Surgery and Prosthetic Devices; Diabetes Equipment, Supplies and Service; Off-Label Cancer Drug Coverage and Pervasive Developmental Disorders Treatment Benefit. See the Policy on File with the school for further details on these benefits.

EXCLUSIONS

The Policy does not cover loss nor provide benefits for any of the following, except as otherwise provided by the benefits of the Policy and as shown in the Schedule of Benefits.

Medical services rendered by a provider employed by or contracted with the School, including team physicians or trainers, except as provided in the Schedule of Benefits.
Loss resulting from war or any act of war, whether declared or not, or loss sustained while in the armed forces of any country or international authority, unless indicated otherwise on the Insurance Information Schedule.
Services or supplies in connection with eye examinations, eyeglasses or contact lenses or hearing aids, except those resulting from a covered accidental Injury.
Loss incurred as the result of riding as a passenger or otherwise (including skydiving) in a vehicle or device for aerial navigation, except as a fare paying passenger in an aircraft operated by a scheduled airline maintaining regular published schedules on a regularly established route anywhere in the world.
Loss resulting from playing, practicing, traveling to or from, or participating in, any intercollegiate or profes sional sports in excess of $1,000.
Preventive medicines, serums or vaccines of any kind.
Elective surgery or treatment.
Elective abortions.
Dental treatment including orthodontics, braces and orthodontic appliances, except as specified for accidental Injury to the Insured Person’s teeth.
The Insured’s use of alcohol or any drugs unless taken on the advice of a Physician.
Expenses covered under any Workers’ Compensation, occupational benefits plan, mandatory automobile no-fault plan, public assistance program or government plan, except Medicaid.
Expenses incurred after: a) The date insurance terminates as to the Insured Person; b) The Aggregate Lifetime Maximum Benefit for each Covered Injury or Sickness has been attained; and c) The end of the Benefit Period specified in the Benefit Schedule.
Routine physical or other examinations where there are no objective indications of impairment of normal health.
Treatment of alcoholism or drug addiction except as provided for in the Schedule of Benefits.

Preexisting Condition Limitation— (Not applicable to any covered person under the age of 19). The Policy does not cover Preexisting Conditions for the twelve months following effective date of an Insured Person’s coverage. However, we will waive this Limitation for an Insured who:

Is a returning Student or his/her Dependent(s) who has been Continuously Insured, as defined in the Policy, or
Is either a newly enrolled Student or a student who has not been Continuously Insured and who can provide satisfactory evidence of prior Creditable Coverage, as defined in the Policy. The Preexisting Condition Limitation will also be waived for an Insured Dependent who can provide evidence of prior Creditable Coverage.To qualify for this waiver, an Insured or his or her Insured Dependent must fulfill all of the following requirements:
1. He or she must not be covered under any other health insurance.
2. He or she must have had health insurance for a total of 12 months. Coverage of less than 12 months will be credited toward satisfying the Preexisting Condition Limitation. This provision will be effective provided the Insured becomes eligible and applies for coverage under the Policy within 63 days of the termination of his or her prior coverage.
3. His or her most recent coverage must meet the definition of Creditable Coverage in the Policy.

Coordination of Benefits—For the Supple mental Medical Expense portion of the Plan, the Company will coordinate benefits according to the COB provision of the Policy on file at the Business Office of the college.

NOTE: The time you were covered under this plan may count as creditable coverage under State and Federal Law if you leave this plan and go to an employer’s plan within 63 days thereafter. You are eligible to receive a certification from the Company regarding the periods you were covered. Please contact Wells Fargo Insurance Services at 1-800-228-6768 when you need such verification.

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.

Claim 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, physician records, etc. Please submit all appeal requests to the Claims Administrator listed on back panel.

Protecting Health Information
Commercial Travelers Mutual Insurance Company is committed to guarding the protected health 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 (HIPAA), 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.studentplanscenter.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 Insurance Company
c/o Privacy Officer
70 Genesee Street • Utica, NY 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 in this brochure, 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.

The effective date of this Plan is prior to the July 1st compliance requirement of the March 16th HHS ruling pertaining to Student Health Insurance. This plan is not PPACA compliant.