CHOATE ROSEMARY HALL

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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. 10 11 12
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. 13 14 15
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CHOATE ROSEMARY HALL

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