CHOATE ROSEMARY HALL

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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