CHOATE ROSEMARY HALL

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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. 4 5 6
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; 7 8 9
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CHOATE ROSEMARY HALL

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