CHOATE ROSEMARY HALL

CHOATE
ROSEMARY HALL
DOMESTIC AND
INTERNATIONAL STUDENT
ACCIDENT AND SICKNESS
INSURANCE PLAN
2012-2013
Policy Number: 2012I5A18
1. This Brochure is not the insurance contract. It is a brief
description of the general provisions provided under Master
Policy issued to Choate Rosemary Hall and underwritten by
Niagara Life and Health Insurance Company.
2. Please be sure to retain this brochure as a record of your
insurance benefits. No individual policies are issued. An
identification card will be issued to each insured person after
October 15, 2012, the Waiver deadline.
THIS POLICY MEETS CONNECTICUT MINIMUM STANDARDS
FOR BASIC MEDICAL/SURGICAL EXPENSE INSURANCE. IT
ALSO CONTAINS ADDITIONAL BENEFITS. PLEASE READ THIS
BROCHURE CAREFULLY.
THIS LIMITED HEALTH BENEFITS PLAN (PLAN A) DOES NOT
PROVIDE COMPREHENSVE MEDICAL COVERAGE. IT IS A
BASIC OR LIMITED BENEFITS POLICY AND IS NOT INTENDED
TO COVER ALL MEDICAL EXPENSES. THIS PLAN IS NOT
DESIGNED TO COVER THE COSTS OF SERIOUS OR
CHRONIC ILLNESS. IT CONTAINS SPECIFIC DOLLAR LIMITS
THAT WILL BE PAID FOR MEDICAL SERVICES WHICH MAY
NOT BE EXCEEDED. IF THE COST OF SERVICES EXCEEDS
THOSE LIMITS, THE BENEFICIARY AND NOT THE INSURER IS
RESPONSIBLE FOR PAYMENT OF THE EXCESS AMOUNTS.
THE SPECIFIC DOLLAR LIMITS ARE AS FOLLOWS IN THE
PLAN BENEFIT SECTION.
Form #12-I5A18(bro/cert)
ELIGIBILITY
All students attending the school on a full-time basis are eligible
to enroll in this Plan. This coverage is available to Domestic and
International Students that travel abroad while the policy is in
force.
The Company maintains 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.
POLICY TERM
The insurance under Choate Rosemary Hall’s Student Accident
and Sickness Insurance Plan for the Annual Plan is effective
12:01 a.m. on September 1, 2012. You may enroll in this
Insurance Program prior to the start of the School Year, or
during the forty-five (45) day period beginning with the start of
the first semester. This is known as the Open Enrollment
Period. The Annual Plan terminates at 12:01 a.m. on
September 1, 2013 or at the end of the period for which the
premiums are paid.
COST OF COVERAGE
DOMESTIC AND INTERNATIONAL
Plan A: Annual Premium (12 months) ......................... $240*
Domestic Only
Plan B: Accident & Sickness Insurance Plan
(12 months) .................................................................. $979*
Domestic & International Students – International Students are
required to enroll in Plan B
*Plans A and B include a $10.00 administration fee.
REFUND OF PREMIUM
Except for medical withdrawal due to a covered Injury or
Sickness, any student withdrawing from school during the first
31 days of the period for which coverage is purchased will not
be covered under the Policy and a full refund of the premium
will be made. Students withdrawing after such 31 days will
remain covered under the Policy for the full period for which
premium has been paid and no refund will be allowed.
Covered Persons entering the armed forces of any country will
not be covered under the Policy as of the date of such entry. A
pro-rata refund of premium will be made for such person upon
written request received by the Company within 90 days of
withdrawal from school. Refunds for any other reason are not
available.
DEFINITIONS
You, Your or Yours means the insured student.
We, Us or Our means Niagara Life and Health Insurance
Company.
Accident means a sudden, unexpected and unforeseen,
identifiable event causing Injury.
Aggregate Maximum Benefit means the Maximum benefit We
will pay for any one covered Injury or Sickness.
Covered Person means You, the Student while insured under
this Plan.
Physician as used herein means: (a) a legally qualified
physician licensed by the state in which he or she practices; or
(b) a practitioner of the healing arts performing services within
the scope of his or her license as specified by the laws of the
state or residence of such practitioner; or (c) a certified nurse
midwife while acting within the scope of that certification; or (d)
a certified nurse practitioner, which means any registered nurse
licensed in the state in which he or she practices who has
completed a formal educational nurse practitioner program and is
certified by the respective professional nursing association; or (e)
a physician assistant performing services within the scope of his
or her license as specified by the laws of the state of residence of
such practitioner.
Hospital means a facility which meets all of these tests: (a) it
provides inpatient services for the care and treatment of injured
and sick people; and (b) it provides room and board services and
nursing services 24 hours a day; and (c) it has established
facilities for diagnosis and major surgery; and (d) it is supervised
by a Physician; and (e) it is run as a Hospital under the laws of the
jurisdiction in which it is located. Hospital does not include a place
run mainly: (a) for alcoholics or drug addicts; (b) as a
convalescent home; (c) as a nursing or rest home; or (d) as a
hospice facility.
Hospital Confined/Confinement means a stay of 18 or more
consecutive hours as a resident bed-patient in a Hospital.
Loss means medical expense covered by this Plan as a result of
Injury or Sickness as defined in this Plan.
Injury means bodily Injury due to an Accident, which is the sole
cause of the Loss and results solely, directly and independently of
disease, bodily infirmity or any other causes. All injuries sustained
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in any one Accident, including all related conditions and recurrent
symptoms of these injuries are considered a single injury.
Sickness means Illness, disease, and complications of
pregnancy which is the sole cause of the Loss which begin after
the effective date of a Covered Person’s coverage, which are not
a Pre-Existing Condition. All related conditions and recurrent
symptoms of the same or a similar condition will be considered
the same Sickness.
Medical Emergency means the unexpected onset of an Injury or
Sickness which requires immediate or urgent medical attention
which, if not provided, could result in a loss of life or serious
permanent damage to a limb or organ or pain sufficient to warrant
immediate care. A Medical Emergency does not include elective
or routine care.
Medically Necessary means Health care services that a physician,
exercising prudent clinical judgment, would provide to a patient for
the purpose of preventing, evaluating, diagnosing or treating an
illness, injury, disease or its symptoms, and that are: (1) In
accordance with generally accepted standards of medical
practice; (2) clinically appropriate, in terms of type, frequency,
extent, site and duration and considered effective for the
patient's illness, injury or disease; and (3) not primarily for the
convenience of the patient, physician or other health care
provider and not more costly than an alternative service or
sequence of services at least as likely to produce equivalent
therapeutic or diagnostic results as to the diagnosis or
treatment of that patient's illness, injury or disease. For the
purposes of this section, "generally accepted standards of
medical practice" means standards that are based on credible
scientific evidence published in peer-reviewed medical literature
generally recognized by the relevant medical community or
otherwise consistent with the standards set forth in policy
issues involving clinical judgment.
Expense or Covered Charge as used herein means those
charges for Medically Necessary treatment, services or supplies
which are performed or given under the direction of a Physician
which are: (a) not in excess of the charges of the Reasonable and
Customary Expenses therefore; and (b) not in excess of the
charges that would have been made in the absence of this
insurance; and (c) incurred while this Plan is in force as to the
Covered Person.
Reasonable and Customary Charge (R&C) means the usual
amount charged by a Provider for a service or supply, regardless of
insurance coverage, but not more than the amount charged by most
providers in the same area for a similar service.
Pre-existing Condition means a Sickness or Injury for which
medical care, treatment, diagnosis, or advice was received or
recommended within the six months prior to the Covered
Person’s effective date of coverage under the Plan. Routine
follow-up care to determine whether breast cancer has reoccurred
in a person who has been previously determined to be breast
cancer free shall not be considered as medical advice, diagnosis,
care or treatment unless evidence of breast cancer is found
during or as a result of such follow-up. Genetic information shall
not be treated as a condition in the absence of a diagnosis of the
condition related to such information. Pregnancy shall not be
considered as a Pre-Existing Condition.
DESCRIPTION OF BENEFITS
ACCIDENT AND SICKNESS INSURANCE PLAN
DOMESTIC STUDENTS - PLAN A
Plan A is designed for students whose current medical
insurance has a high deductible. This insurance plan provides
coverage from the first dollar of Covered Charges, at 100% of R
& C Charges, up to a maximum of $5,000 per Policy Year.
Accidental Dental Expense Benefit: for Dental treatment as a
result of accidental Injury to sound natural teeth up to a
maximum of $100 per Accident.
Ambulance Expense: Up to the maximum allowable rate
established by the Department of Public Health in accordance
with 19a-177, as amended for Medically Necessary transportation
service to or from a Hospital by an ambulance. This includes
emergency transportation from the place of a covered accident to
a hospital providing the necessary medical care.
DOMESTIC AND INTERNATIONAL STUDENTS - PLAN B
Plan B is designed for those students who have no family
medical insurance. International students are required to enroll
in this plan. This student plan provides coverage from the first
dollar of Covered Charges, at 100% of R & C Charges, up to a
maximum of $200,000 per Injury or Sickness.
When a Covered Injury or Sickness requires: (a) treatment by a
Physician/Surgeon; (b) hospital confinement (room and board
expense should not exceed the semi-private room rate); (c)
services of a licensed nurse practitioner or RN; (d) x-ray
services; (e) use of operating room, anesthesia, laboratory
services; (f) prescribed medicines, plaster casts, surgical
dressings and other Reasonable and Customary Charges
incurred for the treatment of a Covered Injury or Sickness, We
will pay 100% of the Covered Charges incurred for a covered
Accident or Sickness, up to a maximum of $200,000 per Injury
or Sickness.
Accidental Dental Expense Benefit: for Dental treatment as a
result of accidental Injury to sound natural teeth up to a
maximum of $650 per Injury.
Ambulance Expense: Up to the maximum allowable rate
established by the Department of Public Health in accordance
with 19a-177, as amended for Medically Necessary transportation
service to or from a Hospital by an ambulance. This includes
emergency transportation from the place of a covered accident to
a hospital providing the necessary medical care.
REPATRIATION OF REMAINS
FOR DOMESTIC AND INTERNATIONAL STUDENTS
The Company will pay the reasonable covered expenses to return
the Insured Person’s body to his or her home country if he or she
dies. Covered expenses include expenses for embalming,
cremation, coffins, and transportation. The benefit payable may not
exceed $5,000.
STATE MANDATED BENEFITS
Mental Health Conditions Expense Benefit: We will pay benefits
for mental health conditions the same as we would pay for any
other sickness. "Mental Health Conditions" means mental
disorders as defined in the most recent edition of the American
Psychiatric Association's "Diagnostic and Statistical Manual of
Mental Disorders".
Mental Disorders include alcohol dependency and substance
abuse, but do not include mental retardation, learning disorders,
motor skills disorders, communication disorders, caffeine-related
disorders, relational problems, and additional conditions that may be
a focus of clinical attention, that are not otherwise defined as mental
disorders in the most recent edition of the American Psychiatric
Association's "Diagnostic and Statistical Manual of Mental
Disorders”.
In the case of benefits payable for the services of a licensed
physician or psychiatrist, benefits are also payable for the same
services when rendered by the following practitioners or facilities
qualified and licensed in accordance with the requirements of
Chapter 38A Section 488A of the Connecticut General Laws:
psychologist, clinical social worker, marital and family therapist,
alcohol and drug counselor, professional counselor, child guidance
clinic, residential treatment facility, or nonprofit community mental
health center.
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Inpatient Mental Health Conditions: If an Insured Person requires
treatment for mental and nervous disorders during Hospital
Confinement, We will pay the Reasonable and Customary Charge
incurred on the same basis as any other Sickness.
Benefits for Partial Hospitalization: Partial Hospitalization means
continuous treatment consisting of not less than four hours and not
more than twelve hours in any twenty-four hour period under a
program based in a hospital or residential treatment facility. Two
Partial Hospitalization days may be substituted for one inpatient day
in a hospital or related institution.
Outpatient Mental & Nervous Conditions: When the Insured
Person is not hospital confined, We will pay the Reasonable and
Customary Charge incurred for Outpatient Services as any other
illness.
Autism Spectrum Disorder Therapies: We will provide coverage
for physical therapy, speech therapy and occupational therapy
services for the treatment of Autism Spectrum Disorders as set forth
in the most recent edition of the American Psychiatric Association’s
“Diagnostic and Statistical Manual of Mental Disorders,” to the
extent such services are a covered benefit for other diseases and
conditions under the policy.
Epidermolysis Bullosa Treatment: We will provide coverage for
wound care supplies that are medically necessary for the treatment
of epidermolysis bullosa and are administered under the direction of
a physician.
Maternity Coverage: Normal pregnancy, complications of
pregnancy, resulting childbirth, miscarriage or termination of
pregnancy (except for elective abortion) on the same basis as a
covered Sickness. Coverage includes a minimum inpatient stay
of 48 hours for a vaginal delivery and 96 hours for a caesarean
delivery. If the mother and newborn are discharged prior to this
timeframe, after consultation with the Physician, this Plan will
cover 2 follow up visits. The first visit must be within 48 hours of
discharge and the second visit within 7 days.
Newborn Children: A child of the insured Student will be
covered by the Policy for 31 days after the moment of birth.
Coverage for a newborn child will be the same as for any other
Insured Person. Coverage will include Medically Necessary
care or treatment of congenital defects, birth abnormalities, or
premature birth. Upon expiration of the 31 days, dependent
coverage is not available under the policy.
Infertility Treatment Benefits: We will pay the medically
necessary expenses incurred in the diagnosis and treatment of
infertility. Such treatment includes, but is not limited to the
following services related to infertility:
1. ovulation induction;
2. intra-uterine insemination;
3. in-vitro fertilization
4. uterine embryo lavage;
5. embryo transfer;
6. gamete intra-fallopian transfer;
7. zygote intra-fallopian transfer; and
8. low tubal ovum transfer.
Coverage under this benefit is limited:
1. to a covered student until the date of the student’s 40 th
birthday;
2. for ovulation induction to a lifetime maximum benefit of 4
cycles;
3. for intrauterine insemination to a lifetime maximum benefit
of 3 cycles;
4. for lifetime benefits to a maximum of 2 cycles, with not
more than 2 embryo implantations per cycle, for IVF,
gamete intra-fallopian transfer, zygote intra-fallopian or low
tubal ovum transfer, provided each such fertilization or
transfer shall be credited toward the maximum as 1 cycle;
5. for IVF, gamete intra-fallopian transfer, zygote intrafallopian
transfer and low tubal ovum transfer, to those
individuals who have been unable to conceive or produce
conception or sustain a successful pregnancy through less
expensive and medically viable infertility treatment or
procedures covered under the policy. Nothing in this
subdivision shall be construed to deny the coverage
required by this section to any individual who foregoes a
particular infertility treatment or procedure if the
individual’s physician determines that such treatment or
procedure is likely to be unsuccessful;
6. to individuals who have maintained coverage under the
policy and any of the schools’ previous policies for at least
12 months.
7. to require disclosure by the student seeking coverage of
any previous fertility treatment or procedures which the
student received under a different health insurance policy.
For the purpose of this benefit, infertility means the condition
of a presumably healthy individual who is unable to conceive or
produce conception or sustain a successful pregnancy during a
one-year period.
Services provided for under this provision must be performed at
facilities that conform to standards and guidelines established
by the American Society of Reproductive Medicine or the
Society of Reproductive Endocrinology and Infertility. The same
co-payments, deductibles and benefit limits will apply to the
diagnosis and treatment of infertility as those applied to other
medical or surgical benefits under the Policy.
Early Intervention Services– When Dependent coverage is
provided under the Policy, we will pay the expenses incurred for
Medically Necessary early intervention services for eligible
Dependent children not to exceed $6,400 per school year.
These benefits are available for Dependent children who are
not eligible for Connecticut special education and related
services and who are from birth to 36 months of age, inclusive.
Such services are needed because a child:
1. Is experiencing a significant developmental delay as
measured by standardized diagnostic instruments and
procedures, including informed clinical opinion, in one or
more of the following areas:
a. Cognitive development;
b. Physical development, including vision and hearing;
c. Communication development;
d. Social or emotional development; or
e. Adaptive skills.
2. Has been diagnosed as having a physical or mental
condition that has a high probability of resulting in
developmental delay.
No payment made under this benefit will be applied against the
Aggregate Maximum Benefit per covered Sickness.
Hearing Aids: We will pay the expenses incurred for the cost
of hearing aids for children 18 years of age and younger. Such
hearing aids will be considered durable medical equipment
under this policy. The maximum benefit payable for any one
child will be limited to $1,000.
Cancer Screening Tests: We will pay for the charges incurred
for the following cancer screening tests.
1. Mammography performed according to following schedule:
a. One or more mammograms per year, as
recommended by a Physician, for any woman at risk
for breast cancer;
b. A baseline mammogram for any woman age 35 to 39,
inclusive, or more frequently if recommended by the
woman’s Physician;
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c. A mammogram every year for any woman who is 40
years of age and older; and
d. Comprehensive ultrasound screening of an entire
breast or breasts if such screenings are
recommended by a physician for a woman classified
as category 2, 3, 4 or 5 under the breast Imaging
Reporting and Data System established by the
American College of Radiology.
2. PAP tests for woman 18 years and older as recommended
by a Physician.
3. Prostate cancer screening, including digital rectal
examinations and prostate-specific antigen tests for men
who are symptomatic; whose biological father or brother
has been diagnosed with prostate cancer, and for all men
50 years of age or older.
4. Colorectal Cancer Screening, including but not limited to
an annual fecal occult blood test, and a colonoscopy,
flexible sigmoidoscopy or radiologic imaging, in
accordance with the recommendations established by the
American College of Gastroenterology, after consultation
with the American Cancer Society, based on the ages,
family histories and frequencies provided in the
recommendations.
Home Health Care Expense: Expenses for covered home
health care service in lieu of Hospitalization, except if
diagnosed by a Physician as terminally ill with a prognosis of 6
months or less to live, after a $50 deductible, 75% of the
Expenses incurred, up to a maximum of 80 home health care
visits in any calendar year or in any continuous period of 12
months for each Covered Person. Each 4 hours of home health
aide service will count as one visit. In the case of a terminally ill
Covered Person, no more than $200 for medical social services
for any 12-month period will be paid for covered services.
Accidental Ingestion of Controlled Drugs Expense: Expenses
for a Medical Emergency arising from accidental ingestion or
consumption of a controlled drug limited to:
• Inpatient: While Hospital Confined, Expense incurred, up to
a maximum of 80% of R&C up to 30 days in any calendar
year.
• Outpatient: While not Hospital Confined, Expense paid at
80% of R&C up to a maximum of $500 per calendar year.
Chiropractic Care Expense: Services rendered by a licensed
chiropractor, to the same extent coverage is provided for services
rendered by a Physician, if such chiropractic services (1) treat a
condition covered under this Plan and (2) are within those
services a chiropractor is licensed to perform.
Treatment of Leukemia, Prosthetic Devices, Surgical
Removal of Tumors Expense: Surgical removal of tumors and
treatment of leukemia, including outpatient chemotherapy,
reconstructive surgery, cost of any non-dental prosthesis
including maxillo-facial prosthesis used to replace anatomic
structures lost during treatment for head and neck tumors or
additional appliances essential for the support of such
prosthesis, and outpatient chemotherapy following surgical
procedure in connection with the treatment of tumors. Such
benefits shall be subject to the same terms and conditions
applicable to all other benefits under this Plan. We will pay a
Policy year benefit of: (1) $1,000 each policy year for the costs
of removal of any breast implant; (2) $500 for the surgical
removal of tumors; (3) $500 for reconstructive surgery; (4) $500
for outpatient chemotherapy; and (5) An annual benefit of at
least $350 for a wig and $300 for prosthesis, except that for
purposes of the surgical removal of breast due to tumors, the
policy year benefit shall be at least $300 for each breast.
Hypodermic Needles or Syringes Expense: Physician
prescribed hypodermic needles or syringes for the purpose of
administering medications for medical conditions, provided
such medications are covered under this Plan.
Treatment of Inherited Metabolic Diseases and Medically
Necessary Formulas: We will pay the expenses incurred for
medical foods and low protein modified food products on the same
basis as outpatient prescription drugs for the treatment of inherited
Metabolic Diseases if the medical food or low protein modified food
products are:
a. Prescribed as Medically Necessary for the therapeutic
treatment of inherited metabolic diseases; and
b. Administered under the direction of a Physician.
In so far as this benefit is concerned, the following definitions apply.
Inherited metabolic disease means a disease for which a
newborn screening is required under section 19a-55 (Connecticut),
as amended; and cystic fibrosis
Low Protein Modified Food Product means a food product that is:
a. Specially formulated to have less than 1 gram of protein per
serving; and
b. Intended to be used under the direction of a Physician for
the dietary treatment of an inherited metabolic disease.
Low protein modified food product does NOT include a natural food
that is naturally low in protein.
Amino acid modification preparation means a product intended
for the dietary treatment of an inherited metabolic disease under the
direction of a physician.
Specialized formula means a nutritional formula for children up to
the age twelve (12) that is exempt from the general requirements for
nutritional labeling under the statutory and regulatory guidelines of
the federal Food and Drug Administration and is intended for use
solely under medical supervision in the dietary management of
specific diseases.
Diabetes Treatment Expense: Treatment of insulin-dependent
diabetes, insulin-using diabetes, gestational diabetes and non-
Insulin using diabetes on the same basis as any other Sickness to
include:
1. Medically Necessary equipment, drugs and supplies, when
prescribed by a Doctor.
2. Diabetes outpatient self-management training, including but
not limited to education and medical nutrition therapy.
Benefits shall cover: (a) Initial training visits provided to an
individual after the individual is initially diagnosed with the
diabetes that is medically necessary for the care and
management of diabetes, including but not limited to
counseling in nutrition and the proper use of equipment and
supplies for the treatment of diabetes, totaling a maximum of
ten hours; (b) training and education that is medically
necessary as a result of a subsequent diagnosis by a Doctor
or a significant change in the individual’s symptoms or
condition which requires modification of the individual’s
program of self-management of diabetes, totaling a
maximum of four hours, and (c) training and education that
is medically necessary because of the development of new
techniques and treatment for diabetes totaling a maximum of
four hours.
Treatment of Lyme Disease: We will pay the expenses incurred
for the treatment of Lyme Disease. Such treatment will include:
1. Not less than 30 days of intravenous antibiotic therapy or
sixty days or oral antibiotic, or both, and
2. Further treatment, if recommended by a board certified
rheumatologist, infectious disease specialist or neurologist
who is licensed in accordance with Connecticut statutes or
who is licensed in another state or jurisdiction whose
requirements for practicing in such capacity are substantially
similar to or higher than those of Connecticut.
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Mastectomy, Reconstructive Breast Surgery or Lymph Node
Dissection Expense: Benefits for such surgery will be paid under
the Surgery Benefits. Coverage will be provided for at least 48 hours
of inpatient care following a mastectomy or lymph node surgery.
Coverage will be provided for longer periods of inpatient care if it is
recommended by the patient’s treating Physician after conferring
with the patient. We will also provide benefits for the reasonable
costs of reconstructive surgery on each breast on which a
mastectomy has been performed, and reconstructive surgery on a
non-diseased breast to produce a symmetrical appearance. This
benefit is subject to the same terms and conditions applicable to all
other benefits under this Policy.
Occupational Therapy Expense: We will pay a benefit, not to
exceed 80% of Reasonable and Customary Charges, for the
expenses incurred for occupational therapy received by a Covered
Person as the result of a covered Accident.
Care and Treatment of Insured with an Ostomy: We will pay the
expenses for the care and treatment of an Insured who undergoes
ostomy surgery. Such care and treatment includes coverage for
Medically Necessary appliances and supplies relating to an ostomy
including, but not limited to collection devices, irrigation equipment
and supplies, skin barriers and skin protectors. This benefit will be
payable not to exceed $2,500 per school year.
Pain Management Benefit: We will pay the expenses incurred by
a Covered Person for treatment by or under the management of a
pain management specialist if required. We will also pay the
expenses incurred for pain treatment ordered by such specialist.
Such treatment may include all means necessary to make a
diagnosis and develop a treatment Plan including the use of
necessary medications and procedures.
Hospital Dental Services: We will pay the expenses incurred for
general anesthesia; nursing and related Hospital services
provided in conjunction with inpatient, outpatient or one day
dental services if the following conditions are met:
1. The anesthesia, nursing and related Hospital services are
deemed Medically Necessary by the treating dentist or oral
surgeon and the Insured’s Physician; and
2. The patient is either:
a. Determined by a licensed dentist, in conjunction with a
licensed Physician who specializes in primary care, to
have a dental condition of significant dental complexity
that the condition requires certain dental procedures to
be performed in a Hospital; or
b. A person who has a developmental disability, as
determined by a licensed Physician who specializes in
primary care that places the person at serious risk.
c. Part B benefits will be considered a Covered Sickness
the same as any other Sickness and is not subject to any
dental benefit limits under this Policy.
Cancer Clinical Trials: We will pay the expenses incurred for the
routine patient care costs associated with cancer clinical trials. We
will not pay such costs if they are eligible for reimbursement by
any other entity, including the entity sponsoring the cancer clinical
trial.
Craniofacial Disorders: We will pay the expenses incurred for
the Medically Necessary orthodontic processes and appliances
for the treatment of craniofacial disorders for insured person age
18 and younger. Such processes and appliances must be
prescribed by a craniofacial team recognized by the American
Cleft Palate – Craniofacial Association, except that no benefit will
be paid for cosmetic surgery.
Experimental Treatments: We will pay the expenses incurred by
an Insured Person for experimental treatments, including
procedures, treatments or the use of a drug as experimental if such
procedure, treatment or drug, for the Sickness or condition being
treated or for the diagnosis for which it is being prescribed, has
successfully completed a phase III clinical trial of the Federal Food
and Drug Administration. Such expenses will be paid the same as
for any other Sickness under the applicable benefit provisions of this
Policy, e.g. experimental surgical procedures under the surgery
benefits, experimental drugs under the prescriptions benefits, etc.
If an Insured Person has been diagnosed with a condition that
creates a life expectancy in that person of less than two years
and we have denied a benefit because we feel that it does not
fit the above criteria, an Insured Person may request an
expedited appeal of our decision as provided by this policy.
Prescribed Drugs for Treatment of Cancer: When prescription
drugs are covered under the Policy, we will pay the expenses
incurred for treatment of a type of cancer for which the drug has not
been approved by the Food and Drug Administration, provided the
drug is recognized for treatment of the specific type of cancer in one
of the following established reference compendia:
1. The U.S. Pharmacopeia Drug Information Guide for Health
Care Professionals (USP DI);
2. The American Medical Association's Drug Evaluations (AMA
DE); or
3. The American Society of Hospital Pharmacist's American
Hospital Formulary Service Drug Information (HAFS-DI).
This benefit does NOT include coverage for any experimental or
Investigational drugs or any drug which the federal Food and Drug
Administration has determined to be contradicted for treatment of
the specific type of cancer for which the drug has been prescribed.
Neuropsychological Testing – When Dependent Coverage is
part of the Insured Student’s coverage, We will provide
Neuropsychological Testing for a Covered Child diagnosed
with cancer on or after January 1, 2000 when ordered by a
licensed physician to assess the extent of any cognitive or
developmental delays in the Covered Child due to
chemotherapy or radiation treatment.
Isolation Care and Emergency Services– If an Insured
Person requires Medically Necessary isolation care and/or
emergency services that are provided by the state’s mobile field
hospital We will provide coverage for the same services as for
any other Sickness covered by this Policy. We will pay the
same rates paid under the Medicaid program, as determined by
the Connecticut Department of Social Services.
Injuries Sustained While Insured Intoxicated: We will
provide health care services to treat any Injury sustained while:
1. Insured has an elevated blood alcohol content; or
2. Insured is under the influence of intoxicating liquor or any
drug or both.
For the purpose of this benefit elevated blood alcohol content
means a ratio of alcohol in the blood of such person that is
eight-hundredths of one percent (08%) or more of alcohol by
weight.
CONTINUATION OF COVERAGE
Any Insured Student who has been continuously covered under
this Policy and prior student health insurance plans issued to
Choate Rosemary Hall from one year to the next shall be covered
for conditions first manifesting themselves while continuously
insured, except for benefits payable under prior policies in the
absence of this Policy.
SUBROGATION
If claims are incurred as a result of another person's
negligence, the company has the right, as permitted by law, to
seek reimbursement in accordance with the Policy.
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TERMINATION OF INSURANCE
Benefits are payable under this Policy only for those Covered
Expenses incurred while the Policy is in effect as to the Insured.
No benefits are payable for expenses incurred after the date
the insurance terminates for the Insured.
EXCLUSIONS AND LIMITATIONS
This Policy does not cover nor provide benefits for:
1. Treatment, services or supplies which: are not Medically
Necessary; are not prescribed by a Physician as necessary
to treat a Sickness or Injury; are received without charge or
legal obligation to pay; would not routinely be paid in the
absence of insurance; are received from any family member.
2. Expenses incurred as a result of loss due to war, or any
action of war, declared or undeclared; service in the armed
forces of any country.
3. Injury or Sickness for which benefits are paid under any
Workers Compensation or Occupational Disease law.
4. Cosmetic surgery other than: Reconstructive surgery
incidental to or following surgery resulting from trauma,
infection, or other diseases of the involved part; or
reconstructive surgery as the result of a congenital disease
or anomaly as provided for dependent newborns during the
first 31 days following birth.
5. Riding as a passenger or otherwise in any vehicle or device
for aerial navigation, except as fare-paying passenger in an
aircraft operated by a commercial scheduled airline.
6. Expenses incurred as a result of dental treatment, except as
specifically stated.
7. Eyeglasses, contact lenses, hearing aids, or prescriptions or
examinations therefore, except as specifically provided
under mandated benefits.
8. Routine physical examinations and routine testing;
preventive testing or treatment; and screening exams,
except as specifically stated.
9. Suicide or attempted suicide; or intentionally self-inflicted
Injury, unless in conjunction with and as the result of a
diagnosed Mental or Nervous Condition as defined and
covered under the Policy.
10. Treatment in a government Hospital, unless there is a
legal obligation for the Covered Person to pay for such
treatment.
11. Injury sustained as the result of a motor vehicle Accident
to the extent that benefits are recovered or recoverable
under no-fault benefits insurance.
PRE-EXISTING CONDITION LIMITATION
Pre-existing Conditions are not covered for the first 12 months
following a Covered Person’s Effective Date of coverage under
the Policy. This limitation will not apply if:
1. The Covered Person has been covered under the Policy
for more than 12 months; or
2. The individual seeking coverage under the Policy was
previously covered under prior Creditable Coverage which
was continuous to a date not less than 120 days prior to
the effective date of coverage under the Policy (150 days
prior to the effective date of coverage under the Policy if
prior Creditable Coverage terminated due to an involuntary
loss of employment) provided the Covered Person applied
for coverage under the Policy within 30 days of initial
eligibility.
Creditable Coverage includes coverage under any of the
following without a break in coverage of 120 days or more: a
group health plan; health insurance coverage; Medicaid or
Medicare; a State Health Benefit Risk Pool; United States
military sponsored health care; Public Health Plan; the Federal
Employees Health benefit plan; a medical care program of the
Indian Health Service or of a tribal organization; a health plan
under the Peace Corp Act. See Policy on file with the school for
a full definition of Creditable Coverage.
CLAIMS PROCEDURES FOR DOMESTIC AND
INTERNATIONAL STUDENTS
In the event of an Injury or Sickness the Insured Student
should:
1. If at Choate Rosemary Hall, report immediately to the
Health Center so that proper treatment can be prescribed
or approved, and obtain a claim form; or
2. If away from Choate Rosemary Hall, or for ob/gyn
treatment, consult a Physician and obtain a claim form
from Willis of CT, LLC or Consolidated Health Plans or at
www.chpstudent.com.
3. Notify the Claims Administrator, Consolidated Health
Plans, within 30 days after the date of the Injury or
commencement of the Sickness, or as soon thereafter as
is reasonably possible.
4. Complete the claim form in full. The completed claim form
should be mailed within 90 days from the date of Injury or
from the date of the first medical treatment for a Sickness,
or as soon as reasonably possible. Retain a copy for your
records and mail a copy to the Claims Administrator,
Consolidated Health Plans, at the address listed on the
following page.
5. Itemized medical bills must be attached to the claim form
at the time of submission. Subsequent medical bills should
be mailed promptly to the Claims Administrator at the
address listed on the following page. No additional claim
forms are needed as long as the Insured Student’s name
and identification number are included on the bill. Direct all
questions regarding benefits available under the Policy,
claim procedures, status of a submitted claim or payment
of a claim to the Claims Administrator, Consolidated
Health Plans at the address below.
REMEMBER THAT EACH INJURY OR SICKNESS IS A
SEPARATE CONDITION AND A SEPARATE CLAIM FORM IS
REQUIRED FOR EACH CONDITION.
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 requests to the
following:
Consolidated Health Plans
2077 Roosevelt Avenue
Springfield, MA 01104
The Policy is Underwritten By:
Niagara Life and Health Insurance Company of Columbia, SC
Policy Form: NLH-SH5-12 (CT)
For a copy of the privacy notice you may:
go to
www.consolidatedhealth plan.com/about/hipaa
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
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(Please indicate the school you attend with your written request)
Servicing Agent:
Willis of CT, LLC
185 Asylum Street, 25 th Floor
Hartford, CT 06103
(860) 278-1320 or (800) 843-5404, ext. 45391
Claims Administered By:
Consolidated Health Plans
2077 Roosevelt Avenue
Springfield, MA 01104
(800) 633-7867
www.chpstudent.com
Any provision of the Policy or the brochure which is in conflict
with the statutes of the state in which the Policy is issued, will
be administered to conform to the requirements of the state
statues.
Representations of this plan must be approved by the
Company.
EMERGENCY MEDICAL AND TRAVEL ASSISTANCE
FrontierMEDEX ACCESS services is a comprehensive
program providing You with 24/7 emergency medical and travel
assistance services including emergency security or political
evacuation, repatriation services and other travel assistance
services when you are outside Your home country or 100 or
more miles away from your permanent residence.
FrontierMEDEX is your key to travel security.
For general inquiries regarding the travel access
assistance services coverage, please call Consolidated
Health Plans at 1-800-633-7867.
If you have a medical, security, or travel problem, simply call
FrontierMEDEX for assistance and provide your name, school
name, the group number shown on your ID card, and a
description of your situation. If you are in North America, call
the Assistance Center toll-free at: 1-800-527-0218 or if you are
in a foreign country, call collect at: 1-410-453-6330.
If the condition is an emergency, you should go
immediately to the nearest physician or hospital without
delay and then contact the 24-hour Assistance Center.
FrontierMEDEX will then take the appropriate action to
assist You and monitor Your care until the situation is
resolved.
VISION DISCOUNT PROGRAM
For Vision Discount Benefits please go to:
www.chpstudent.com
CHOATE ROSEMARY HALL
Insurance Election Form
2012-2013
Sickness and Accident Coverage
Students Name: _____________________________________
Date of Birth: _______________
I understand that proof of medical insurance is required for
attendance at Choate Rosemary Hall. The school Student
Insurance Plan underwritten by Niagara Life and Health
Insurance Company will extend from 9/1/2012 – 9/1/2013 and
cover the student while attending school, at home, and while
traveling.
DOMESTIC & INTERNATIONAL STUDENTS
I select one of the following options:
Plan A (Domestic Only): Since I have viable medical
insurance available for my child, I elect this plan, which is
primary over my own insurance. (Please check with your
insurance company to see if benefits will extend to services
rendered in Connecticut. Most HMO’s and PPO Plans do not). I
understand that Plan A is designed for students whose current
medical insurance has a high deductible. The Policy pays
covered expenses up to 100% of R&C to a maximum of
$5,000 per year.
Premium: $240
Plan B (Domestic & International): Since I do not have a
viable medical insurance Policy for my child or I have HMO
coverage, I elect this plan which will serve as his/her primary
insurance. The plan pays up to 100% of R&C of covered
expenses incurred from injury or sickness up to a
maximum of $200,000 for each incident.
Premium: $979
I elect to waive all of the above coverage as I am currently
covered under a U.S. viable medical insurance policy. I will
maintain health Insurance coverage throughout my child’s CHR
career and will provide the Health Center with updated cards as
necessary. Attached is a copy of both sides of my
insurance card.
I am covered by: _________________________________
My Policy # is: ___________________________________
Parent’s Signature: ___________________________________
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The following information is required if ELECTING a
Student Insurance Plan.
STUDENT INFORMATION M F
Are you a U.S. Citizen? Yes No
Student Name: ______________________________________
Date of Birth: _______________
__________________________________________________
HOME Street Address
__________________________________________________
City, State, Zip
__________________________________________________
Parents Signature
Please return this form with your check in the enclosed
envelope by October 15, 2012 to:
Consolidated Health Plans
2077 Roosevelt Avenue
Springfield, MA 01104
OR
You may enroll on-line at: www.chpstudent.com.
We accept both MasterCard and Visa.
For questions, please contact your servicing agent, Willis of CT,
LLC at 1-800-843-5404, ext. 45391.
Form EF-I5A18
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