Southern New Hampshire University International Students & Scholars
administered by Cultural Insurance Services International • River Plaza • 9 West Broad Street • Stamford, CT 06902-3788 This plan is underwritten by The Insurance Company of the State of Pennsylvania, a member of Chartis, Inc. Policy terms and conditions are briefly outlined in this Description of Coverage. Complete provisions pertaining to this insurance are contained in the Master Policy on file with the trustee, Group Insurance Trust, Washington, D.C. and the Participating Organization. In the event of any conflict between this Description of Coverage and the Master Policy, the Policy will govern.
Schedule of Benefits
Coverage and Services Section I
Policy # GLB 9111664 Maximum Limits
Accident and Sickness Medical Expenses
The Company will pay Covered Expenses due to Accident or Sickness only, as per the limits stated in the Schedule of Benefits. Coverage is limited to Covered Expenses incurred subject to Exclusions. All bodily Injuries sustained in any one Accident shall be considered one Disablement, all bodily disorders existing simultaneously which are due to the same or related causes shall be considered one Disablement. If a Disablement is due to causes which are the same or related to the cause of a prior Disablement (including complications arising there from), the Disablement shall be considered a continuation of the prior Disablement and not a separate Disablement. Treatment of an Injury or Illness must occur within 30 days of the Accident or onset of the Illness. When a covered Injury or illness is incurred by the Insured Person the Company will pay Reasonable and Customary medical expenses excess of the Deductible and Coinsurance as stated in the Schedule of Benefits. In no event shall the Company’s maximum liability exceed the maximum stated in the Schedule of Benefits as to Covered Expenses during any one period of individual coverage. The Deductible and Coinsurance amount consists of Covered Expenses which would otherwise be payable under this Policy. These expenses must be borne by the Insured Person.
• Medical expenses (per Accident or Sickness): Deductible Basic Medical Major Medical Catastrophic Major Medical • Emergency Medical Reunion $50 $5,000 at 100% $45,000 at 80% $100,000 at 100% $1,500
• Team Assist Plan (TAP): 24/7 medical, travel, technical assistance • Emergency Medical Evacuation • Repatriation/Return of Mortal Remains • Team Assist Plan (TAP # GLB 9111664) $100,000 $50,000
Benefits are payable under this Policy for Covered Expenses incurred by an Insured Person for the items stated in the Schedule of Benefits. Benefits shall be payable to either the Insured Person or the Service Provider for Covered Expenses incurred Worldwide. The first such expense must be incurred by an Insured within 30 days after the date of the Accident or commencement of the Sickness; and • All expenses must be incurred by the Insured within 52 weeks from the date of the Accident or commencement of the Sickness; and • The Insured must remain continuously insured under the Policy for the duration of the treatment. The charges enumerated herein shall in no event include any amount of such charges which are in excess of Reasonable and Customary charges. If the charge incurred is in excess of such average charge such excess amount shall not be recognized as a Covered Expense. All charges shall be deemed to be incurred on the date such services or supplies, which give rise to the expense or charge, are rendered or obtained.
Covered Accident and Sickness Medical Expenses
Only such expenses, incurred as the result of a Disablement, which are specifically enumerated in the following list of charges, and which are not excluded in the Exclusions section, shall be considered as Covered Expenses: • Charges made by a Hospital for semi-private room and board to a