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2010-202384-76 brochure-v1.qxp

STUDENT INJURY AND SICKNESSINSURANCE PLAN Limited Benefit PlanPlease Read CarefullyLimited benefits health insurance. The insurance evidenced by this certificateprovides limited benefits health insurance only. It does NOT provide basichospital, basic medical, or major medical as defined by the New York StateInsurance Department.
Table of Contents
Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Extension of Benefits after Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Accidental Death And Dismemberment Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Benefits for Maternity Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Benefits for Cervical Cytological Screening and Mammograms . . . . . . . . . . . . . . . . .8Benefits for Diabetes Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Benefits for Treatment of Chemical Dependence (Alcoholism and Drug Abuse) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Benefits for Medical Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Prostate Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Benefits for Second Medical Opinion for Diagnosis of Cancer . . . . . . . . . . . . . . . . .11Benefits for Prescription Drugs for the Treatment of Cancer . . . . . . . . . . . . . . . . . . .11Benefits for End of Life Care for Terminally Ill Cancer Patients . . . . . . . . . . . . . . . . .12Benefits for Mental and Nervous Disorder Treatment . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Bone Mineral Density Measurements or Tests . . . . . . . . . . . . . . . . . . . .13Benefits for Biologically Based Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Children with Serious Emotional Disturbances . . . . . . . . . . . . . . . . . . . .14Benefits for Contraceptive Drugs or Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Benefits for Breast Cancer Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . .18Insured Person’s Right to an External Appeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back CoverClaims Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back Cover Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality ofyour nonpublic personal information. We do not disclose any nonpublic personalinformation about our customers or former customers to anyone, except as permitted orrequired by law. We believe we maintain appropriate physical, electronic and proceduralsafeguards to ensure the security of your nonpublic personal information. You may obtaina copy of our privacy practices by calling us toll-free at 1-800-767-0700 or visiting us atwww.uhcsr.com.
Eligibility
All registered students taking 9 or more credit hours are eligible to enroll in this insurancePlan.
Students must actively attend classes for at least the first 31 days after the date for whichcoverage is purchased. Home study, correspondence, Internet, and television (TV) coursesdo not fulfill the Eligibility requirements that the student actively attend classes. TheCompany maintains its right to investigate student status and attendance records to verifythat the policy Eligibility requirements have been met. If the Company discovers that thePolicy Eligibility requirements have not been met, its only obligation is to refund premium.
Eligible students may also insure their Dependents. Eligible Dependents are the spouseand unmarried children under 19 years of age or 23 years if a full-time student at anaccredited institution of higher learning, who are not self-supporting. Full-time dependentstudents who take a medical leave of absence from school may continue to be dependentfor a period of 12 months from the last day of attendance, provided, however that thecoverage will not extend beyond the limiting age for full-time students. Dependent Eligibilityexpires concurrently with that if the Insured student.
Effective and Termination Dates
The Master Policy on file at the school becomes effective August 21, 2010. Coveragebecomes effective on the first day of the period for which premium is paid or the date theenrollment form and full premium are received by the Company (or its authorizedrepresentative), whichever is later. The Master Policy terminates August 20, 2011.
Coverage terminates on that date or at the end of the period through which premium is paid,whichever is earlier. Dependent coverage will not be effective prior to that of the Insuredstudent or extend beyond that of the Insured student.
Refunds of premiums are allowed only upon entry into the armed forces.
The Policy is a Non-Renewable One Year Term Policy.
Extension of Benefits after Termination
The coverage provided under the Policy ceases on the Termination Date. However, if anInsured is Hospital Confined on the Termination Date from a covered Injury or Sickness forwhich benefits were paid before the Termination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long as the condition continues but not toexceed 90 days after the termination date.
The total payments made in respect of the Insured for such condition both before and afterthe Termination Date will never exceed the Maximum Benefit.
Pre-Admission Notification
UMR Care Management should be notified of all Hospital Confinements prior to admission.
1. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS: The patient, Physician or Hospital should telephone 1-877-295-0720 at least fiveworking days prior to the planned admission.
2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient’s representative, Physician or Hospital should telephone 1-877-295-0720 within twoworking days of the admission to provide the notification of any admission due toMedical Emergency.
UMR Care Management is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00p.m., C.S.T., Monday through Friday. Calls may be left on the Customer Service Department’svoice mail after hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwisepayable under the policy; however, pre-notification is not a guarantee that benefits will bepaid.
Up To $50,000 Maximum Benefit As Specified Below (For Each Injury or Sickness) Deductible Preferred Providers $100 (For each Injury and Sickness) Deductible Out of Network $200 (For each Injury and Sickness) The Policy provides benefits for the Usual and Customary Charges incurred by an Insuredperson for loss due to a covered Injury or Sickness up to the Maximum Benefit of$50,000 for each Injury or Sickness.
The Preferred Provider for this plan is UnitedHealthcare Options PPO.
If care is received from a Preferred Provider any Covered Medical Expenses will be paidat the Preferred Provider level of benefits. If the Covered Medical Expenses is incurreddue to a Medical Emergency, benefits will be paid at the Preferred Provider level ofbenefits. In all other situations, reduced or lower benefits will be provided when an Out-of-Network provider is used.
All benefit maximums are combined Preferred Provider and Out-of-Network, unlessotherwise noted below. Benefits will be paid up to the Maximum Benefit for each serviceas scheduled below. Covered Medical Expenses include: Preferred Allowance = PA Usual & Customary = U&C Hospital Expenses, daily semi-private room rate; general nursing care provided by the Hospital; Hospital Miscellaneous Expenses, such as the cost of the operating room,laboratory test, x-ray examinations, anesthesia,drugs (excluding take home drugs) ormedicines, therapeutic services, and supplies. Incomputing the number of days payable underthis benefit, the date of admission will becounted, but not the date of discharge.
Confined; and routine nursery care providedimmediately after birth.
Surgeon’s Fees, in accordance with data provided by Ingenix. If two or more procedures are performed through the same incision or inimmediate succession, the maximum amountpaid will not exceed 50% of the secondprocedure and 50% of all subsequentprocedures.
Registered Nurse’s Services, private duty Physician’s Visits, benefits are limited to one visit per day and do not apply when related tosurgery.
Psychotherapy, benefits are limited to one visit See Benefits for Mental and Nervous Disorder Treatment, Benefits for Biologically Based Mental Illness and Benefits for Children with Surgeon’s Fees, in accordance with data provided by Ingenix. If two or more procedures are performed through the same incision or inimmediate succession, the maximum amountpaid will not exceed 50% of the secondprocedure and 50% of all subsequentprocedures.
scheduled surgery performed in a Hospital, including the cost of the operating room;laboratory tests and x-ray examinations,including professional fees; anesthesia; drugs ormedicines; and supplies. Usual and CustomaryCharges for Day Surgery Miscellaneous arebased on the Outpatient Surgical Facility ChargeIndex.
Anesthetist, professional services administered in connection with outpatient surgery.
Outpatient Miscellaneous, includes benefits Miscellaneous Benefit including Physician’sVisits, Physiotherapy, diagnostic x-ray services,radiation therapy, laboratory procedures, andtests and procedures, chemotherapy.
Physician’s Visits, including chiropractic care.
Benefits are limited to one visit per day. Benefits for Physician’s Visits do not apply when relatedto surgery or Physiotherapy.
Physiotherapy, all chiropractic care is payable under Physician’s Visits. Benefits are limited toone visit per day.
emergency room and supplies. Treatment must be rendered within 72 hours from time of Injuryor first onset of Sickness. $250 Maximum if not admitted. Diagnostic X-Ray & Laboratory Services Prescription Drugs, $500 maximum Per Policy See Benefits for Mental and Nervous Disorder ancillary charges incurred as a result of a Mental Treatment, Benefits for Biologically Based Mental& Nervous Disorder, including Prescription Illness and Benefits for Children with Serious Drugs. Benefits are limited to one visit per day. prescription must accompany the claim whensubmitted. Replacement equipment is notcovered. $400 maximum. Consultant Physician Fees, when requested and approved by the attending Physician.
Dental Treatment, $500 maximum. Made necessary by Injury to Sound, Natural Teeth.
Preferred Provider Information
“Preferred Providers” are the Physicians, Hospitals and other health care providers whohave contracted to provide specific medical care at negotiated prices. Preferred Providersin the local school area are: The availability of specific providers is subject to change without notice. Insureds shouldalways confirm that a Preferred Provider is participating at the time services are required bycalling the Company at (800) 767-0700 and/or by asking the provider when making anappointment for services.
"Preferred Allowance" means the amount a Preferred Provider will accept as payment infull for Covered Medical Expenses.
"Out of Network" providers have not agreed to any prearranged fee schedules. Insuredsmay incur significant expenses with these providers. Charges in excess of the insurancepayment are the Insured’s responsibility.
Regardless of the provider, each Insured is responsible for the payment of their Deductible.
The Deductible must be satisfied before benefits are paid. The Company will pay accordingto the benefit limits in the Schedule of Benefits.
Inpatient Hospital Expenses PREFERRED HOSPITALS - Eligible inpatient Hospital expenses at a Preferred Hospitalwill be paid at coinsurance percentage specified in the Schedule of Benefits, up to anylimits specified in the schedule of Benefits. Call (800) 767-0700 for information aboutPreferred Hospitals.
OUT-OF-NETWORK HOSPITALS - If care is provided at a Hospital that is not a PreferredProvider, eligible inpatient Hospital expenses will be paid according to the benefit limits inthe Schedule of Benefits.
Outpatient Hospital Expenses Preferred Providers may discount bills for outpatient Hospital expenses. Benefits are paidaccording to the Schedule of Benefits. Insureds are responsible for any amounts thatexceed the benefits shown in the Schedule, up to the Preferred Allowance.
Professional & Other Expenses Benefits for Covered Medical Expenses provided by UnitedHealthcare Options PPO will bepaid at coinsurance percentage specified in the Schedule of Benefits or up to any limitsspecified in the Schedule of Benefits. All other providers will be paid according to thebenefit limits in the Schedule of Benefits.
Maternity Testing
This policy does not cover routine, preventive or screening examinations or testing unlessMedical Necessity is established based on medical records. The following maternity routinetests and screening exams will be considered, if all other policy provisions have been met.
This includes a pregnancy test, CBC, Hepatitis B Surface Antigen, Rubella Screen, SyphilisScreen, Chlamydia, HIV, Gonorrhea, Toxoplasmosis, Blood Typing ABO, RH Blood AntibodyScreen, Urinalysis, Urine Bacterial Culture, Microbial Nucleic Acid Probe, AFP BloodScreening, Pap Smear, and Glucose Challenge Test (at 24-28 weeks gestation). OneUltrasound will be considered in every pregnancy, without additional diagnosis. Anysubsequent ultrasounds can be considered if a claim is submitted with the PregnancyRecord and Ultrasound report that establishes Medical Necessity. Additionally, thefollowing tests will be considered for women over 35 years of age: Amniocentesis/AFPScreening and Chromosome Testing. Fetal Stress/Non-Stress tests are payable. Pre-natalvitamins are not covered. For additional information regarding Maternity Testing, please callthe Company at 1-800-767-0700.
Accidental Death And Dismemberment Benefits
Loss of Life, Limb or SightIf such Injury shall independently of all other causes and within 90 days from the date ofInjury solely result in any one of the following specific losses, the Company will pay theapplicable amount below. Payment under this benefit will not exceed the policy MaximumBenefit.
For Loss Of: Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or armsand feet or legs, dismemberment by severance at or above the wrist or ankle joint; withregard to eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater)resulting from any one Injury will be paid.
Excess Provision
No benefits are payable for any expense occurred for Injury or Sickness which has beenpaid or is payable by other valid and collectible insurance.
However, this Excess Provision will not be applied to the first $100 of medical expensesincurred.
Covered Medical Expenses excludes amounts not covered by the primary carrier due topenalties imposed as a result of the Insured’s failure to comply with policy provisions orrequirements.
Important: The Excess Provision has no practical application if you do not have othermedical insurance or if your group insurance does not cover the loss Mandated Benefits
Benefits will be paid the same as any other Sickness for pregnancy. Benefits will includecoverage for an Insured mother and newborn confined to a Hospital as a resident inpatientfor childbirth, but, in no event, will benefits be less than: 1. 48 hours after a non-cesarean delivery; or2. 96 hours after a cesarean section.
Benefits for maternity care shall include the services of a certified nurse-midwife underqualified medical direction. The Company will not pay for duplicative routine servicesactually provided by both a certified nurse-midwife and a Physician.
Benefits will be paid for: 1. parent education;2. assistance and training in breast or bottle feeding; and3. the performance of any necessary maternal and newborn clinical assessments.
In the event the mother chooses an earlier discharge, at least one home visit will be availableto the mother, and not subject to any deductibles, coinsurance, or copayments.
The first home visit, (which may be requested at any time within 48 hours of the time ofdelivery, or within 96 hours in the case of a cesarean section) shall be conducted within 24hours following: 1. discharge from the Hospital; or2. the mother’s request; whichever is later.
Except for the one home visit after early discharge, all benefits shall be subject to allDeductible, copayment, coinsurance, limitations, or any other provisions of the policy.
If the Insured Person's insurance should expire, the policy will pay under this benefitproviding conception occurred while the policy was in force.
Benefits for Cervical Cytological Screening and Mammograms Benefits will be paid the same as any other Sickness for cervical cytology screening andmammograms. (a) Benefits will be paid for an annual cervical cytology screening for women (18) eighteen years of age and older. This benefit shall include an annual pelvicexamination, collection and preparation of a Pap smear, and laboratory anddiagnostic services provided in connection with examining and evaluating the Papsmear.
(b ) Benefits will be paid for mammograms as follows: (1) Upon a Physician's recommendation, Insureds at any age who are at risk for breast cancer or who have a first degree relative with a prior history of breastcancer, and (2) a single base line mammogram for Insureds age 35 but less than 40, and(3) a mammogram every year for Insureds age 40 and older.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or anyother provisions of the policy.
Benefits will be paid the same as any other Sickness for the following equipment andsupplies for the treatment of diabetes. Such equipment and supplies must berecommended or prescribed by a Physician. Covered Medical Expenses includes but arenot limited to the following equipment and supplies: (a) lancets and automatic lancing devices;(b) glucose test strips;(c) blood glucose monitors;(d) blood glucose monitors for the visually impaired;(e) control solutions used in blood glucose monitors;(f) diabetes data management systems for management of blood glucose;(g) urine testing products for glucose and ketones;(h) oral anti-diabetic agents used to reduce blood sugar levels;(i) alcohol swabs;(j) syringes;(k) injection aids including insulin drawing up devices for the visually impaired;(l) cartridges for the visually impaired;(m) disposable insulin cartridges and pen cartridges;(n) all insulin preparations;(o) insulin pumps and equipment for the use of the pump including batteries;(p) insulin infusion devices;(q) oral agents for treating hypoglycemia such as glucose tablets and gels; and(r) glucagon for injection to increase blood glucose concentration.
Benefits will also be paid for medically necessary diabetes self-management education andeducation relating to diet. Such education may be provided by a Physician or the Physician'sstaff as a part of an office visit. Such education when provided by a certified diabetes nurseeducator, certified nutritionist, certified dietitian or registered dietitian upon referral by aPhysician may be provided in a group setting. When medically necessary, self-managementeducation and diet education shall also include home visits.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Treatment of Chemical Dependence (Alcoholism and Drug Abuse) Benefits will be paid the same as any other Sickness for treatment of ChemicalDependence and Chemical Abuse subject to the following limits:Outpatient Treatment: Outpatient benefits are limited to one outpatient visit per day and include the following: (a) up to a maximum of 60 outpatient visits per calendar year for the Insured Person (b) up to a maximum of 20 visits per calendar year for covered Family Members, (including visits for remediation through counseling and education), provided thatthe total number of such visits, when combined with those of the Insured Personin need of treatment, does not exceed 60 visits in any calendar year.
Inpatient benefits in a Hospital or a detoxification facility will be paid the same as any otherSickness not to exceed 7 days of active treatment per policy year. For rehabilitationservices, benefits will be paid the same as any other Sickness not to exceed 30 days ofinpatient care per policy year.
Benefits will be limited to facilities in New York state certified by the office of alcoholismand substance abuse services or licensed by such office as outpatient clinic or medicallysupervised ambulatory substance abuse programs and in other states to those which areaccredited by the joint commission on accreditation of hospitals as alcoholism or ChemicalDependence treatment programs.
"Chemical abuse" means alcohol and substance abuse.
"Chemical dependence" means alcoholism and substance dependence.
“Family Member” means those family members covered under the insurance policycovering the person receiving or in need of treatment for alcoholism or substance abuse.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
If Prescription Drugs are covered in the Policy, benefits will be paid the same as any otherSickness for Prescription Drugs for the cost of enteral formulas for home use which areprescribed by a Physician as medically necessary for the treatment of specific diseases forwhich enteral formulas have been found to be an effective form of treatment. Specificdiseases for which enteral formulas have been found to be an effective form of treatmentinclude, but are not limited to inherited disease of amino-acid or organic metabolism;Crohn's disease; gastroesophagael reflux with failure to thrive, disorders of gastrointestinalmotility such as chronic intestinal pseudo-obstruction; and multiple severe food allergieswhich if left untreated will cause malnourishment, chronic physical disability, mentalretardation or death.
Benefits will also be paid for the medically necessary Usual and Customary Charges formodified solid food products that are low protein or which contain modified protein fortreatment of certain inherited diseases of amino acid and organic acid metabolism not toexceed a maximum benefit of $2,500 in any 12 month period.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits will be paid the same as any other Sickness for a prostate examination andlaboratory tests for cancer for an Insured at any age with a prior history of prostate cancer;at age 50 and over for Insureds who are asymptomatic; and at age 40 and over for Insuredswith a family history of prostate cancer or other prostate cancer risk factors.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Second Medical Opinion for Diagnosis of Cancer Benefits will be paid the same as any other Sickness for a second medical opinion by anappropriate Physician, including but not limited to a Physician affiliated with a specialty carecenter for the treatment of cancer, in the event of a positive or negative diagnosis of canceror a recurrence of cancer or a recommendation of a course of treatment for cancer.
Benefits will be paid at the Preferred Provider level of benefits for a second medical opinionby a non-participating Physician, including but not limited to a Physician affiliated with aspecialty care center for the treatment of cancer, when the attending Physician provides awritten referral to a non-participating Physician. If the Insured receives a second medicalopinion from a non-participating Physician without a written referral, benefits will be paid atthe Out-of-Network level of benefits.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Prescription Drugs for the Treatment of Cancer If Prescription Drugs are covered in the Policy, benefits will be paid the same as any otherSickness for Prescription Drugs for the treatment of cancer provided that the drug has beenrecognized for treatment of the specific type of cancer for which the drug has beenprescribed in one of the following established reference compendia: 1. the American Medical Association Drug Evaluations;2. the American Hospital Formulary Service Drug Information; or3. the United States Pharmacopeia Drug Information; or4. recommended by review article or editorial comment in a major peer reviewed Benefits will not be paid for any experimental or investigational drugs or any drug which thefood and drug administration has determined to be contraindicated for treatment of thespecific type of cancer for which the drug has been prescribed.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for End of Life Care for Terminally Ill Cancer Patients Benefits will be paid the same as any other Sickness for Covered Medical Expenses foracute care services at Hospitals specializing in the treatment of terminally ill patients forthose Insured's diagnosed with advanced cancer (with no hope of reversal of primarydisease and fewer than sixty days to live, as certified by the Insured's attending Physician)if the Insured's attending Physician, in consultation with the medical director of the Hospital,determines that the Insured's care would appropriately be provided by the Hospital.
If the Company disagrees with the admission of or provision or continuation of care for theInsured at the Hospital, the Company will initiate an Expedited External Appeal. Until suchdecision is rendered, the admission of or provision or continuation of the care by theHospital shall not be denied by the Company and the Company shall provide benefits andreimburse the Hospital for Covered Medical Expenses. The decision of the External AppealAgent shall be binding on all parties. If the Company does not initiate an Expedited ExternalAppeal, the Company shall reimburse the Hospital for Covered Medical Expenses.
The Company shall provide reimbursement at rates negotiated between the Company andthe Hospital. In the absence of agreed upon rates, the Company will reimburse theHospital’s acute care rate under the Medicare program and shall reimburse for alternatelevel care days at seventy-five percent of the acute care rate. Payment by the Companyshall be payment in full for the services provided to the Insured. The Hospital shall notcharge or seek any reimbursement from, or have any recourse against an Insured for theservices provided by the Hospital except for any applicable Deductible, copayment orcoinsurance.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Mental and Nervous Disorder Treatment Benefits will be paid the same as any other Sickness for the diagnosis and treatment ofmental, nervous or emotional disorders. Benefits for inpatient Hospital care are limited to30 days of Active Treatment per policy year. For the purposes of this benefit, two partialdays of Hospital Confinement will be combined to equal one day of inpatient Hospital care.
Outpatient care provided by a Physician or facility licensed by the commissioner of mentalhealth or operated by the office of mental health is limited to 20 visits per policy year.
“Active Treatment” means treatment furnished in conjunction with inpatient confinement formental, nervous or emotional disorders or ailments that meet standards prescribed pursuantto the regulations of the commissioner of mental health.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or otherprovision of the Policy.
Benefits for Bone Mineral Density Measurements or Tests Benefits will be paid the same as any other Sickness for bone mineral densitymeasurements or tests, and if coverage for Prescription Drugs, drugs and devices isotherwise provided in the policy, coverage for federally approved Prescription Drugs anddevices.
Bone mineral density measurements or tests, drugs and devices shall include thosecovered under Medicare as well as those in accordance with the criteria of the nationalinstitutes of heath, including, as consistent with such criteria, dual-energy x-rayabsorptiometry.
Individuals qualifying for benefits shall at a minimum, include individuals: (a) previously diagnosed as having osteoporosis or having a family history of (b) with symptoms or conditions indicative of the presence, or the significant risk, of (c) on a prescribed drug regimen posing a significant risk of osteoporosis; or(d) with lifestyle factors to such a degree as posing a significant risk of osteoporosis; (e) with such age, gender and/or other physiological characteristics which pose a Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Biologically Based Mental Illness Benefits will be paid the same as any other Sickness for adults and children diagnosed withBiologically Based Mental Illness.
“Biologically Based Mental Illness”means a mental, nervous, or emotional condition that iscaused by a biological disorder of the brain and results in a clinically significant,psychological syndrome or pattern that substantially limits the functioning of the personwith the illness. Such Biologically Based Mental Illnesses are defined as: 1. schizophrenia/psychotic disorders,2. major depression,3. bipolar disorder,4. delusional disorders,5. panic disorder, 6. obsessive compulsive disorder, 7. bulimia and anorexia.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or otherprovision of the Policy.
Benefits for Children with Serious Emotional Disturbances Benefits will be paid the same as any other Sickness for Children with Serious EmotionalDisturbances.
“Children with Serious Emotional Disturbances” means persons under the age of eighteenyears who have diagnoses of attention deficit disorders, disruptive behavior disorders, orpervasive development disorders and where there are one or more of the following: 1. serious suicidal symptoms or other life-threatening self-destructive behaviors;2. significant psychotic symptoms (hallucinations, delusion, bizarre behaviors;3. behavior caused by emotional disturbances that placed the child at risk of causing personal injury or significant property damage; or 4. behavior caused by emotional disturbances that placed the child at substantial risk Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or otherprovision of the Policy.
Benefits for Contraceptive Drugs or Devices If Prescription Drugs are covered in the Policy, benefits will be paid the same as any otherPrescription Drug for prescription contraceptive drugs and devices approved by the Foodand Drug Administration (FDA) or generic equivalents approved as substitutes by the FDA.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations or any otherprovisions of the policy.
Benefits for Breast Cancer Treatment Benefits will be paid the same as any other Sickness for medically appropriate care asdetermined by the attending Physician in consultation with the Insured for a lymph nodedissection, a lumpectomy or mastectomy for the treatment of breast cancer.
Breast reconstructive surgery after a mastectomy will also be paid as any other Sicknessfor medically appropriate care as determined by the attending Physician in consultation withthe Insured. Benefits will be paid for 1) all stages of reconstruction of the breast on whichthe mastectomy has been performed; 2) surgery and reconstruction of the other breast toproduce a symmetrical appearance; and 3) prostheses and any physical complications ofall stages of mastectomy, including lymphedemas.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Definitions
INJURY means bodily injury which is: 1) directly and independently caused by specificaccidental contact with another body or object; 2) unrelated to any pathological, functional,or structural disorder; 3) a source of loss; 4) treated by a Physician within 30 days after thedate of accident; and 5) sustained while the Insured Person is covered under this policy. Allinjuries sustained in one accident, including all related conditions and recurrent symptomsof these injuries will be considered one injury. Injury does not include loss which resultswholly or in part, directly or indirectly, from disease or other bodily infirmity. Covered MedicalExpenses incurred as a result of an injury that occurred prior to this policy's Effective Datewill be considered a Sickness under this policy.
PRE-EXISTING CONDITION means any condition for which medical advice, diagnosis,care or treatment was recommended or received within the 6 months immediately prior tothe Insured's enrollment date under the policy.
SICKNESS means sickness or disease of the Insured Person which causes loss, andoriginates while the Insured Person is covered under this policy. All related conditions andrecurrent symptoms of the same or a similar condition will be considered one sickness.
Covered Medical Expenses incurred as a result of an Injury that occurred prior to thispolicy's Effective Date will be considered a sickness under this policy.
USUAL AND CUSTOMARY CHARGES means a reasonable charge which is: 1) usualand customary when compared with the charges made for similar services and supplies;and 2) made to persons having similar medical conditions in the locality of the Policyholder.
No payment will be made under this policy for any expenses incurred which in the judgmentof the Company are in excess of Usual and Customary Charges.
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: 1. Assistant Surgeon Fees;2. Chemical Dependence (Alcoholism/Drug Abuse), except as specifically provided in Benefits for Chemical Dependence (Alcoholism/Drug Abuse); 3. Cosmetic procedures, except that cosmetic procedures does not include reconstructive surgery when such surgery is incidental to or follows surgery resultingfrom trauma, infection or other disease of the involved part and reconstructive surgerybecause of a congenital disease or anomaly of a covered Dependent child which hasresulted in a functional defect. It also does not include breast reconstructive surgeryafter a mastectomy; 4. Custodial Care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or custodial care;extended care in treatment or substance abuse facilities for domiciliary or custodialcare; 5. Dental treatment, except for accidental Injury to Sound, Natural Teeth or due to 6. Elective Surgery or Elective Treatment; 7. Elective Abortion;8. Eye examinations, prescriptions or fitting of eyeglasses or contact lenses. Vision correction, or other treatment for visual defects and problems; except when due to adisease process or a Medical Necessity; 9. Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet; 10. Hearing examinations. or hearing aids; or other treatment for hearing defects and problems. "Hearing defects" means any physical defect of the ear which does or canimpair normal hearing, apart from the disease process; 11. The Insured’s being intoxicated or under the influence of any narcotic unless administered on the advise of a Physician; 12. Injury for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 13. Injury sustained by reason of a motor vehicle accident to the extent that benefits are paid or payable by mandatory automobile no-fault benefits; 14. Injury sustained while a) participating in any interscholastic sport, contest or competition; b) traveling to or from such sport, contest or competition as a participant;or c) while participating in any practice or conditioning program for such sport, contestor competition; 15. Investigational services or experimental treatment, except for experimental or investigational treatment approved by an External Appeal Agent in accordance withInsured Persons Right to an External Appeal. If the External Appeal Agent approvesbenefits of an experimental or investigational treatment that is part of a clinical trial,this policy will only cover the costs of services required to provide treatment to theInsured according to the design of the trial. The Company shall not be responsible forthe cost of investigational drugs or devices, the costs of non-health care services, thecost of managing research, or costs which would not be covered under this policy fornon-experimental or non-investigational treatments provided in such clinical trial; 16. Outpatient Physiotherapy; except for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2)within the 30 days immediately following the attending Physician’s release forrehabilitation; 17. Marital or family counseling;18. Participation in a felony, riot or insurrection;19. Pre-existing Conditions, except for individuals who have been continuously insured under the school’s student insurance policy for at least 12 consecutive months. ThePre-existing Condition exclusionary period will be reduced by the total number ofmonths that the Insured was covered under Creditable Coverage which wascontinuous to a date not more than 63 days prior to the Insured’s enrollment dateunder this policy; 20. 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 asspecifically provided in the Benefits for Diabetes Expense; b. Drugs labeled, “Caution - limited by federal law to investigational use” or c. Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra, except when a Medical Necessity; d. Refills in excess of the number specified or dispensed after one (1) year of date of 21. Preventive medicines, serums, vaccines or immunizations; 22. Routine Newborn Infant Care, well-baby nursery and related Physician charges, except as specifically provided in the Benefits for Maternity Expense; 23. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specificallyprovided in the policy; 24. Services provided normally without charge by the Student Health Center of the Policyholder; or services covered or provided by the student health fee; 25. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; 26. Suicide or attempted suicide or intentionally self-inflicted Injury;27. Supplies; except as specifically provided in the policy;28. Treatment, service or supply which is not a Medical Necessity, subject to Article 49 of 29. Treatment in a Government hospital, unless there is a legal obligation for the Insured 30. 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 notcovered).
Collegiate Assistance Program
Insured Students have access to nurse advice and health information 24 hours a day, 7days a week by dialing the access number indicated on the permanent ID Card. TheCollegiate Assistance Program is staffed by Registered Nurses who can help studentsdetermine if they need to seek medical care, understand their medications or medicalprocedures, or learn ways to stay healthy.
Scholastic Emergency Services:
Global Emergency Medical Assistance

If you are a student insured with this insurance plan, you and your insured spouse and minorchild(ren) are eligible for Scholastic Emergency Services (SES). The requirements toreceive these services are as follows:International Students, insured spouse and insured minor child(ren): You are eligible toreceive SES worldwide, except in your home country.
Domestic Students, insured spouse and insured minor child(ren): You are eligible for SESwhen 100 miles or more away from your campus address and 100 miles or more away fromyour permanent home address or while participating in a Study Abroad program. SES includes Emergency Medical Evacuation and Return of Mortal Remains that meet theUS State Department requirements. The Emergency Medical Evacuation services are notmeant to be used in lieu of or replace local emergency services such as an ambulancerequested through emergency 911 telephone assistance. All SES services must bearranged and provided by SES, Inc.; any services not arranged by SES, Inc. will not beconsidered for payment. Key Services include: * Medical Consultation, Evaluation and Referrals * Prescription Assistance* Foreign Hospital Admission Guarantee * Lost Luggage or Document Assistance* Care for Minor Children Left Unattended Due to a Medical Incident Please visit your school's insurance coverage page at www.uhcsr.com for the SES GlobalEmergency Assistance Services brochure which includes service descriptions and programexclusions and limitations.
To access services please cal :(877) 488-9833 Toll-free within the United States(609) 452-8570 Collect outside the United StatesServices are also accessible via e-mail at medservices@assistamerica.com.
When calling the SES Operations Center, please be prepared to provide: 1. Caller's name, telephone and (if possible) fax number, and relationship to the patient;2. Patient's name, age, sex, and Reference Number;3. Description of the patient's condition;4. Name, location, and telephone number of hospital, if applicable;5. Name and telephone number of the attending physician; and6. Information of where the physician can be immediately reached.
SES is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan andare subject to the policy limits of your health coverage. All assistance services must bearranged and provided by SES, Inc. Claims for reimbursement of services not provided bySES will not be accepted. Please refer to your SES brochure or Program Guide atwww.uhcsr.com for additional information, including limitations and exclusions pertaining tothe SES program.
Insured Person’s Right to an External Appeal
An Insured Person or an Insured's representative and, in connection with a RetrospectiveAdverse Determination, an Insured's Physician have a right to an external appeal of a denialof benefits. If benefits are denied under this policy on the basis that the service is not aMedical Necessity or is an experimental or investigational treatment, an Insured Person orhis representative and, in connection with a Retrospective Adverse Determination, anInsured's Physician may appeal that decision to an External Appeal Agent. An ExternalAppeal Agent is an independent entity certified by New York State to conduct suchappeals.
A Retrospective Adverse Determination is a determination for which utilization review wasinitiated after health care services have been provided. Retrospective AdverseDetermination does not mean a pre-authorization denial or a determination involvingcontinued or extended health care services or additional services for a patient undergoinga course of continued treatment Insured Person's Right To Appeal A Determination That A Service Is Not A MedicalNecessity If benefits are denied under this policy on the basis that the service is not a MedicalNecessity, an Insured Person may appeal to an External Appeal Agent if the Insured Personsatisfies the following two (2) criteria: 1. The service, procedure or treatment must otherwise be a Covered Medical Expense 2. The Insured Person must have received a final adverse determination through the Company's internal appeal process and the Company must have upheld the denialor the Insured Person and the Company must agree in writing to waive any internalappeal.
Insured Person's Rights To Appeal A Determination That A Service Is ExperimentalOr Investigational If benefits are denied under this policy on the basis that the service is an experimental orinvestigational treatment, an Insured Person may appeal to an External Appeal Agent if theInsured Person satisfies the following two (2) criteria: 1. The service must otherwise be a Covered Medical Expense under this policy; and2. The Insured Person must have received a final adverse determination through the Company's internal appeal process and the Company must have upheld the denialor the Insured Person and the Company must agree in writing to waive any internalappeal.
In addition, the Insured Person's attending Physician must certify that the Insured Personhas a Life-Threatening or Disabling Condition or Disease. A "life-threatening condition ordisease" is one which, according to the current diagnosis of the Insured Person's attendingPhysician, has a high probability of death. A "disabling condition or disease" is any medicallydeterminable physical or mental impairment that can be expected to result in death, or thathas lasted or can be expected to last for a continuous period of not less than twelve (12)months, which renders the Insured Person unable to engage in any substantial gainfulactivities.
In the case of a child under the age of eighteen, a "disabling condition or disease" is anymedically determinable physical or mental impairment of comparable severity.
The Insured Person's attending Physician must also certify that the Insured Person's Life-Threatening or Disabling Condition or Disease is one for which standard health services areineffective or medically inappropriate or one for which there does not exist a more beneficialstandard service or procedure covered by this policy or one for which there exists a clinicaltrial (as defined by law).
In addition, the Insured Person's attending Physician must have recommended one of thefollowing: 1. A service, procedure or treatment that two (2) documents from available medical and scientific evidence indicate is likely to be more beneficial to the Insured Person thanany standard covered service (only certain documents will be considered in supportof this recommendation - the Insured Person's attending Physician should contactthe New York State Department of Insurance in order to obtain current informationas to what documents will be considered acceptable); or 2. A clinical trial for which the Insured Person is eligible (only certain clinical trials can For the purposes of this section, the Insured Person's attending Physician must be alicensed, board-certified or board eligible physician qualified to practice in the areaappropriate to treat the Insured Person's Life-Threatening or Disabling Condition orDisease.
The External Appeal Process If, through the Company's internal appeal process, the Insured Person has received a finaladverse determination upholding a denial of benefits on the basis that the service is not aMedical Necessity or is an experimental or investigational treatment, the Insured Person has45 days from receipt of such notice to file a written request for an external appeal.
If the Insured Person and the Company have agreed in writing to waive any internal appeal,the Insured Person has 45 days from receipt of such waiver to file a written request for anexternal appeal. The Company will provide an external appeal application with the finaladverse determination issued through the Company's internal appeal process or its writtenwaiver of an internal appeal.
The Insured Person may also request an external appeal application from the New YorkState Department of Insurance at 1(800) 400-8882. The completed application should besubmitted to the New York State Department of Insurance at the address indicated on theapplication. If the Insured Person or, where applicable, the Insured's Physician satisfies thecriteria for an external appeal, the New York State Department of Insurance will forward therequest to a certified External Appeal Agent.
The Insured Person and the Insured's Physician, where applicable, will have an opportunityto submit additional documentation with his request. If the External Appeal Agentdetermines that the information the Insured Person submits represents a material changefrom the information on which the Company based its denial, the External Appeal Agent willshare this information with the Company in order for the Company to exercise its right toreconsider its decision.
If the Company chooses to exercise this right, the Company will have three (3) businessdays to amend or confirm its decision. Please note that in the case of an expedited appeal(described below), the Company does not have a right to reconsider its decision.
In general, the External Appeal Agent must make a decision within 30 days of receipt ofthe Insured Person's completed application. The External Appeal Agent may requestadditional information from the Insured Person, his Physician or the Company. If the ExternalAppeal Agent requests additional information, it will have five (5) additional business daysto make its decision. The External Appeal Agent must notify the Insured Person in writingof its decision within two (2) business days.
If the Insured Person's attending Physician certifies that a delay in providing the service thathas been denied poses an imminent or serious threat to the Insured Person's health, theInsured Person may request an expedited external appeal. In that case, the External AppealAgent must make a decision within three (3) days of receipt of the completed application.
Immediately after reaching a decision, the External Appeal Agent must try to notify theInsured Person and the Company by telephone or facsimile of that decision. The ExternalAppeal Agent must also notify the Insured Person in writing of its decision.
If the External Appeal Agent overturns the Company's decision that a service is not aMedical Necessity or approves benefits for an experimental or investigational treatment, theCompany will provide benefits subject to the other terms and conditions of this policy.
Please note that if the External Appeal Agent approves benefits for an experimental orinvestigational treatment that is part of a clinical trial, this policy will only cover the costs ofservices required to provide treatment to the Insured Person according to the design of thetrial. The Company shall not be responsible for the costs of investigational drugs or devices,the costs of non-health care services, the costs of managing research, or costs which wouldnot be covered under this policy for non-experimental or non-investigational treatmentsprovided in such clinical trial.
The External Appeal Agent's decision is binding on both the Insured Person and theCompany. The External Appeal Agent's decision is admissible in any court proceeding.
The Company will charge the Insured Person a fee of $50 for an external appeal. Theexternal appeal application will instruct the Insured Person on the manner in which he mustsubmit the fee. The Company will also waive the fee if the Company determines that payingthe fee would pose a hardship to the Insured Person. If the External Appeal Agent overturnsthe denial of benefits, the fee shall be refunded to the Insured Person.
Insured Person's and Insured Person's Physician's Responsibilities It is the Insured Person's or, for appeal of a Retrospective Adverse Determination, theInsured's Physician's responsibility to initiate the external appeal process. The externalappeal process may be initiated by filing the completed appropriate application with theNew York State Department of Insurance (For Insureds, New York State External AppealApplication for Health Care Consumers; for Physicians, New York State External AppealApplication for Health Care Providers. For Retrospective Adverse Determination appeals,the Insured Person must sign an acknowledgement of the request and sign a consent torelease of medical records.
Under New York State law, the completed request for appeal must be filed within 45 daysof either the date upon which written notification from the Company that it has upheld adenial of benefits is received or the date upon which written waiver of any internal appealis received. The Company has no authority to grant an extension of this deadline.
Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs,correspondence and coverage information via My Account at www.uhcsr.com. Insureds canalso print a temporary ID card, request a replacement ID card and locate network providersfrom My Account. If you don’t already have an online account, simply select the “Create an Account” link fromthe home page at www.uhcsr.com. Follow the simple, onscreen directions to establish anonline account in minutes. Note that you will need your 7-digit insurance ID number tocreate an online account. If you already have an online account, just log in fromwww.uhcsr.com to access your account information.
Claims Procedure
In the event of Injury or Sickness, the students should: 1. Report to Foreman Hall Student Health Services for treatment, or when not in school, to their Physician or Hospital.
2. Mail to the address below all medical and Hospital bills, along with the patient’s name and Insured Student’s name, address, Student’s ID number and the name ofthe college under which the student is insured. A Company claim form is notrequired for filing a claim.
3. File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 120 days of service or as soon as possible.
UnitedHealthcare Insurance Company of New York Please keep this Certificate as a general summary of the insurance. The Master Policy onfile at the College contains all of the provisions, limitations, exclusions and qualifications ofyour insurance benefits, some of which may not be included in this Certificate. The MasterPolicy is the contract and will govern and control the payment of benefits.
This Certificate is based on Policy # 2010-202384-76

Source: http://www.tkc.edu/students/resources/pdf/InsuranceBrochure.pdf

Jose_dutra_crohn_disease.pdf

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patientsnotpatents.org

Nos. 2006-1213, -1313 Plaintiff/Counterclaim Defendant-Appellant, MERRELL PHARMACEUTICALS, INC., AND CARDERM CAPITAL L.P., Defendant/Counterclaimant-Appellee, On appeal from the United States District Court for the District of New Jersey in consolidated case Nos. 01-CV-3627 and 03-CV-0487, Judge Joseph A. Greenway, Jr. BRIEF OF PATIENTS NOT PATENTS, INC., AS AMICUS CURIAE IN SU

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