Microsoft word - sr spc-cayman sb table 15pposb-ci-2016-202852-1.docx

2016–2017 International Student Injury and Sickness Plan PSI – Short Term Plan Who is eligible to enroll? How do I Enroll? All International students with F-1 visas and International To enroll visit www.psiservice.com, and follow instructions. Visiting Scholars with J-1 visas and their Dependents who have been continuously insured for at least 3 consecutive All personal e-mails sent securely from the following months under a Professional Service, Inc. (PSI) policy issued to Global Travelers Organization through Student Resources (SPC) Ltd., whose coverage has terminated because of loss of eligibility, are eligible to enroll in this plan What important dates should I be aware of? for a maximum of 6 months of coverage. Eligible students The Master Policy becomes effective at 12:01 A.M, July 01, may also insure their dependents. Eligible Dependents are 2016. The individual student's coverage becomes effective the student's spouse and dependent children under 26 on the first day of the period for which premium is paid or the date the enrollment form and full premium are received by the Company (or its authorized representative), U.S. Citizens are not eligible for coverage as a student or whichever is later. The Master Policy terminates at 11:59 P.M, September 30, 2017. Coverage terminates on that date or at the end of the period through which premium is Who can answer questions I have about the paid, whichever is earlier. Six (6) months is the maximum time coverage can be effective under any policy year for any Insured Person. Dependent coverage will not be effective If you have questions please contact Customer Service at prior to that of the insured student or extend beyond that of 888-302-6182 or [email protected] the insured student. Where can I get more information about the benefits available? Please read the plan brochure to determine whether this plan is right before you enroll. The plan brochure provides details of the coverage including costs, benefits, exclusions, and reductions or limitations and the terms under which the coverage may be continued in force. Copies of the plan brochure may be downloaded at www.psiservice.com. How much does the plan cost? 30 – Day Rates (Requires a 90 Day Minimum) Student 24 & Under *Refunds of premium are allowed only upon entry into the armed forces or ineligibility. This plan is underwritten by Student Resources (SPC) Ltd., a UnitedHealth Group Company and is based on policy number 2016-202852-1. Available through PGH Global and issued to Global Traveler Organization SP. The Policy is a Non-Renewable One Year Term Policy. 15PPOSB-CI-2016-202852-1 Page 1 of 4 Student Resources (SPC) Ltd., Highlights of the Coverage and Services offered by StudentResources (SPC) Ltd., a UnitedHealth Group Company Preferred Providers Out-of-Network Providers Overall Plan Maximum Up to a $250,000 Maximum Benefit (For each Injury or Sickness) $500 Per Insured Person, Per Policy Year 80% of Preferred Allowance for 70% of Usual and Customary Charges All benefits are subject to satisfaction of the Covered Medical Expenses for Covered Medical Expenses Deductible, specific benefit limitations, maximums and Copays as described in the plan brochure. Prescription Drugs 70% of Usual and Customary Charges up to a 31 day supply per prescription ($1,000 Maximum per Policy Year) (The Policy Deductible does not apply) UnitedHealthcare Global: Global Emergency Services International Students are covered worldwide except in their home country. Preferred Providers The Preferred Provider Network for this plan is UnitedHealthcare Options PPO. Preferred Providers can be found using the following link: www.psiservice.com. Online Services Insureds have online access to their claims status, EOBs, ID Cards, network providers, correspondence and coverage account information by logging in to My Account at www.psiservice.com. To create an online account, select the "My Account" link and follow the simple, onscreen directions. All you need is your 7-digit Insurance ID number or the email address on file. Insureds can also download our UHCSR Mobile App available on Google Play and Apple's App Store. Student Assistance Insureds have immediate access to the Student Assistance Program, a service that coordinates care using a network of resources. Services available include counseling, financial and legal advice, as well as mediation. Counseling services are offered by Licensed Clinicians who can provide insureds with someone to talk to when everyday issues become overwhelming. Financial services, provided by licensed CPA's and Certified Financial Planners offer consultations on issues such as financial planning, credit and collection issues, home buying and renting and more. Legal Services are provided by fully credentialed attorneys with at least 5 years of experience practicing law. Mediation services are available to help resolve family-related disputes. Translation services are available in over 170 languages for most services. Insureds also have access to LiveAndWorkWell.com where they can take health risk assessments, use health estimators to calculate things like their target heart rate and BMI, and participate in personalized self-help programs. More information about these services is available by logging into My Account at www.psiservice.com. 15PPOSB-CI-2016-202852-1 Page 2 of 4 Student Resources (SPC) Ltd., Healthiest You: National Telehealth Service conceptual handicap, developmental delay or disorder Starting on the effective date of your policy, you have 24/7 or mental retardation; access to medical advice through HealthiestYou, a national 6. Chemotherapy; Radiation Therapy; Injections; telehealth service. By calling the toll-free number listed on Cosmetic procedures, except cosmetic surgery the front of your medical ID card or visiting required to correct an Injury for which benefits are www.psiservice.com, you have access to board-certified otherwise payable under this policy or for newborn or physicians via phone and/or video, where permitted. This adopted children; service is especially helpful for minor illnesses, such as 8. Custodial Care; care provided in: rest homes, health allergies, sore throat, earache, pink eye, etc. Based on the resorts, homes for the aged, halfway houses, college condition being treated, the doctor can also prescribe infirmaries or places mainly for domiciliary or Custodial certain medications, saving you a trip to the doctor's Care; extended care in treatment or substance abuse office. Using HealthiestYou can save you money and time, facilities for domiciliary or Custodial Care; while avoiding costly trips to a doctor's office, urgent care 9. Dental treatment, except for accidental Injury to Sound, facility, or emergency room. As an insured with StudentResources (SPC) Ltd., A UnitedHealth Group 10. Elective Surgery or Elective Treatment; Company, there is no consultation fee for this service.* Every 11. Elective abortion; call with a HealthiestYou doctor is covered 100% during 12. Eye examinations, eye refractions, eyeglasses, contact your policy period. lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for This service is meant to compliment your Student Health visual defects and problems; except when due to a Center. If possible, we encourage you to visit your SHC first covered Injury or disease process; before using this service. Depending on your school's set- 13. Health spa or similar facilities; strengthening programs; up, your call may be routed to the Student Health Center Hearing examinations; hearing aids; or cochlear during their business hours for further assistance. implants; or other treatment for hearing defects and problems, except as a result of an infection or trauma. HealthiestYou is not health insurance. HealthiestYou is "Hearing defects" means any physical defect of the ear designed to complement, and not replace, the care you which does or can impair normal hearing, apart from the receive from your primary care physician. HealthiestYou disease process; physicians are an independent network of doctors who Immunizations; preventive medicines or vaccines, advise, diagnose, and prescribe at their own discretion. except where required for treatment of a covered Injury; HealthiestYou physicians provide cross coverage and 16. Injury caused by, contributed to, or resulting from the operate subject to state regulations. Physicians in the use of illegal drugs, or any drugs or medicines that are independent network do not prescribe DEA controlled not taken in the recommended dosage or for the substances, non-therapeutic drugs and certain other drugs purpose prescribed by the Insured Person's Physician; which may be harmful because of their potential for abuse. 17. Injury or Sickness for which benefits are paid or payable HealthiestYou does not guarantee that a prescription will be under any Workers' Compensation or Occupational written. Not available in Arkansas; limited services in Disease Law or Act, or similar legislation; California, Idaho, Iowa, Louisiana, and Texas. 18. Injury or Sickness inside the Insured's home country; 19. Injury or Sickness outside the United States and its *If you are an Insured under this insurance Plan, and you possessions, Canada or Mexico, except when traveling call prior to the plan effective date, you will be charged a for academic study abroad programs or pleasure, or to $40 service fee before being connected to a board- or from the Insured's home country; certified physician. Injury or Sickness when claims payment and/or coverage is prohibited by applicable law; PRE-EXISTING CONDITION means any condition which Injury sustained while (a) participating in any is diagnosed, treated or recommended for treatment within interscholastic, intramural, club, or intercollegiate, or the 6 months immediately prior to the Insured's Effective professional sport, contest or competition; (b) traveling Date under the Policy. to or from such sport, contest or competition as a participant; or (c) while participating in any practice or Exclusions and Limitations: conditioning program for such sport, contest or No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or 22. Investigational services; supplies for, at, or related to any of the following: 23. Maternity; pregnancy; and Complications of Pregnancy. 24. Motor vehicle Injury in excess of $25,000; 25. Participation in a riot or civil disorder; commission of or 3. Allergy, including allergy testing; attempt to commit a felony; 4. Assistant Surgeon Fees; 26. Pre-existing Conditions, for a period of 12 months. The 5. Autistic disease of childhood, hyperkinetic syndromes, Pre-existing Condition exclusionary period will be milieu therapy, learning disabilities, behavioral problems, reduced by the total number of months that the Insured parent-child problems, attention deficit disorder, provides documentation of continuous coverage under a prior health insurance policy which provided benefits 15PPOSB-CI-2016-202852-1 Page 3 of 4 Student Resources (SPC) Ltd.,

similar to this policy provided the coverage was 30. Routine Newborn Infant Care, well-baby nursery and continuous to a date within 63 days prior to the related Physician charges; in excess of 48 hours for Insured's effective date under this policy; vaginal delivery or 96 hours for cesarean delivery; 27. Prescription Drugs, services or supplies as follows; 31. Preventive care services; routine physical examinations Therapeutic devices or appliances, including: and routine testing; preventive testing or treatment; hypodermic needles, syringes, support garments screening exams or testing in the absence of Injury or and other non-medical substances, regardless of intended use, except as specifically provided in the Services provided normally without charge by the Health Service of the institution attended by the Insured; b) Birth control and/or contraceptives, oral or other, or services covered or provided by a student health fee; whether medication or device, regardless of 33. Temporomandibular joint dysfunction; deviated nasal septum, including submucous resection and/or other c) Immunization agents, biological sera, blood or surgical correction thereof; nasal and sinus surgery, blood products administered on an outpatient except for treatment of a covered Injury or treatment of chronic purulent sinusitis; d) Drugs labeled, "Caution - limited by federal law to Skydiving, parachuting, hang gliding, glider flying, investigational use" or experimental drugs; parasailing, sail planing, bungee jumping, or flight in any e) Products used for cosmetic purposes; kind of aircraft, except while riding as a passenger on a f) Drugs used to treat or cure baldness; anabolic regularly scheduled flight of a commercial airline; steroids used for body building; 35. Sleep disorders; g) Anorectics - drugs used for the purpose of weight 36. Suicide or attempted suicide while sane or insane (including drug overdose); or intentionally self-inflicted h) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, 37. Surgical breast reduction, breast augmentation, breast Serophene, or Viagra; implants or breast prosthetic devices, or gynecomastia; i) Growth hormones; or except as specifically provided in the policy; Refills in excess of the number specified or 38. Travel in or upon, sitting in or upon, alighting to or from, dispensed after one (1) year of date of the or working on or around any motorcycle or recreational vehicle including but not limiting to: two- or three- 28. Reproductive/Infertility services including but not limited wheeled motor vehicle; four-wheeled all-terrain vehicle to: family planning; fertility tests; infertility (male or (ATV); snowmobile; female), including any services or supplies rendered for 39. Skiing; scuba diving; the purpose or with the intent of inducing conception; 40. Treatment in a Government hospital, unless there is a premarital examinations; impotence, organic or legal obligation for the Insured Person to pay for such otherwise; female sterilization procedures; vasectomy; sexual reassignment surgery; reversal of sterilization 41. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium 29. Research or examinations relating to research studies, will be refunded upon request for such period not or any treatment for which the patient or the patient's representative must sign an informed consent Weight management, weight reduction, nutrition document identifying the treatment in which the patient programs, treatment for obesity, surgery for removal of is to participate as a research study or clinical research excess skin or fat. study, except as specifically provided in the policy; NOTE: The information contained herein is a summary of certain benefits which are offered under a student health insurance policy issued by Student Resources (SPC) Ltd., a UnitedHealth Group Company. This document is a summary only and may not contain a full or complete recitation of the benefits and restrictions/exclusions associated with the relevant policy of insurance. This document is not an insurance policy document and your receipt of this document does not constitute the issuance or delivery of a policy of insurance. Neither you nor Student Resources (SPC) Ltd., a UnitedHealth Group Company has any rights or responsibilities associated with your receipt of this document. Changes in federal, state or other applicable legislation or regulation or changes in Plan design required by the applicable state regulatory authority may result in differences between this summary and the actual policy of insurance. 15PPOSB-CI-2016-202852-1 Page 4 of 4 Student Resources (SPC) Ltd.,

Source: https://www.psiservice.com/psiweb/member/brochure.do?page=2016-202852-0&type=pdf