Web.suffieldacademy.org

2012/13 student forms
date of bIrth
Suffield, Connecticut / 860.386.4400 Medical insurance for suffield acadeMy students Suffield Academy requires that all enrolled students have insurance to cover emergency and other medical services that may be needed while they are at school. Suffield Academy offers an insurance package through the Student Insurance Division of the Mega Insurance Companies. This coverage is used by many independent schools, as well as colleges and universities. This Suffield Academy Insurance Plan is designed for students who do not have existing coverage. A brief description of the coverage follows this form. Your child will receive an identification card and full description of benefits if you enroll in the program for the 2012-2013 school year. Our Health Center coordinates the interaction between health care providers and the insurance company.
The premium cost for the plan offered is $1,720 and it covers the ten-month period from August 15, 2012, through June 14, 2013. If you have any questions, you may call the Business Office at 860-668-7315, or email [email protected].
If you already have medical insurance coverage that will cover your child's expenses while at Suffield Academy, and you have provided written
documentation of that coverage (attach a copy of your insurance card to the Permission for Medical or Surgical Treatment form, or scan and email your
insurance card), please check Box A, sign and return this Waiver/Enrollment form. If you cannot provide such documentation, you will be required
to purchase the Suffield Academy Insurance Plan coverage. In order to enroll your child in the insurance program at Suffield, please check Box B on
this Waiver/Enrollment form, sign the form and return it with your check (in U.S. dollars).
STUDEnT HEAlTH InSUrAnCE WAIvEr/EnrOllMEnT PlEASE CHOOSE EITHEr OPTIOn A (WAIvEr) Or B (EnrOllMEnT) AnD SIgn THE fOrM BElOW A: WAIVER (If you have existing medical insurance coverage)
As parent (guardian), I certify that the student listed above has medical insurance which will cover expenses incurred by illness or injury while attending Suffield Academy. I have provided a copy of the front and back of the insurance card, which will be on file in the Suffield Academy Health Center. I decline enrollment in the Suffield Academy Insurance Plan.
B: ENROLLMENT
If you do not have existing medical insurance for your child, you must enroll in Suffield Academy Insurance Plan. Premium cost is $1,720 (for coverage
through June 14, 2013). Please enroll the above named student in the medical insurance program offered through Suffield Academy. I have enclosed
payment in U.S. Dollars for the premium cost of the Suffield Academy Insurance Plan; I understand that the coverage will begin August 15, 2012, or
when I pay the premium, whichever date is later. Please print this form and send it along with payment to Suffield Academy, Attn. Patrick Booth,
185 North Main Street, Suffield, CT 06078.
Parent or guardian name (please print and sign here if you intend to use a printed copy of this form) By checking this box and entering the student ID number above, you are signing this document electronically.
[FORM: INSURANCE / DUE: 07.15.12 [
STUDENT INJURY AND SICKNESS Designed Especially for Students of This Certificate does not provide coverage for:Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing,bungee jumping, or flight in any kind of aircraft, except while riding as apassenger on a regularly scheduled flight of a commercial airline.
06-BR-CT (Rev 09) Table of Contents
Benefits for Accidental Ingestion of a Controlled Drug . . . . . . . . . . . . . 7Benefits for Hypodermic Needles or Syringes . . . . . . . . . . . . . . . . . 7Benefits for Reconstructive Breast Surgery . . . . . . . . . . . . . . . . . . .8Benefits for Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . .8Benefits for Mammography and Comprehensive Ultrasound Screening . . . . 9Benefits for Ostomy Appliances and Supplies . . . . . . . . . . . . . . . . . 9Benefits for Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . 9Benefits for Treatment of Tumors and Leukemia . . . . . . . . . . . . . . . .10Benefits for Prostate Cancer Testing . . . . . . . . . . . . . . . . . . . . . 10Benefits for Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . .10Benefits for Cancer Clinical Trial . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Benefits for Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . 11Benefits for Amino Acid Modified Preparations and Benefits for Lyme Disease Treatment . . . . . . . . . . . . . . . . . . . . . 11Benefits for Isolation Care and Emergency Services . . . . . . . . . . . . . .11Benefits for Diabetic Outpatient Self-Management Training . . . . . . . . . .12Benefits for Inpatient Dental Services . . . . . . . . . . . . . . . . . . . . . 12Benefits for Treatment of Craniofacial Disorders . . . . . . . . . . . . . . . .12Benefits for Mental or Nervous Conditions . . . . . . . . . . . . . . . . . . .12Benefits for Pain Management . . . . . . . . . . . . . . . . . . . . . . . . 13Benefits for Infertility Treatment . . . . . . . . . . . . . . . . . . . . . . . . 13Benefits for Epidermolysis Bullosa Treatment . . . . . . . . . . . . . . . . . 14 THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDE
COMPREHENSIVE 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 INSURED
AND NOT THE COMPANY IS RESPONSIBLE FOR PAYMENT OF
THE EXCESS AMOUNTS. THE SPECIFIC DOLLAR LIMITS ARE
SPECIFIED IN THE SCHEDULE OF BENEFITS.
We know that your privacy is important to you and we strive to protect the confidentiality ofyour nonpublic personal information. We do not disclose any nonpublic personal informationabout our customers or former customers to anyone, except as permitted or required by law.
We believe we maintain appropriate physical, electronic and procedural safeguards toensure the security of your nonpublic personal information. You may obtain a copy of ourprivacy practices by calling us toll-free at 800-767-0700 or by visiting us at www.uhcsr.com.
All Domestic students registered for credit courses are eligible to enroll in this insurance
Plan.
All International students registered for credit courses are automatically enrolled in this
insurance Plan at registration, unless proof of comparable coverage is furnished.
Students must actively attend classes for at least the first 31 days after the date for which
coverage is purchased. The Company maintains its right to investigate student status and
attendance records to verify that the policy Eligibility requirements have been met. If the
Company discovers the Eligibility requirements have not been met, its only obligation is to
refund premium.
Alternative Coverage - If you do not meet the Eligibility requirements of the Plan, please
call 1-800-406-2338 for more information on alternative coverage. This information can
also be accessed at http://www.goldenrulehealth.com/studentresources.
Effective And Termination Dates
The Master Policy on file at the school becomes effective at 12:01 a.m., August 15, 2012.
Coverage becomes effective on the first day of the period for which premium is paid or thedate the enrollment form and full premium are received by the Company (or its authorizedrepresentative), whichever is later. The Master Policy terminates at 11:59 p.m., June 152013. Coverage terminates on that date or at the end of the period through which premiumis paid, whichever is earlier.
Refunds of premiums are allowed only upon entry into the armed forces.
The Policy is a Non-Renewable One Year Term Policy.
Extension of Benefits After Termination
The coverage provided under the Policy ceases on the Termination Date. However, if anInsured is Totally Disabled on the Termination Date from a covered Injury or Sickness forwhich benefits were paid before the Termination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long as the condition continues but not toexceed 90 days after the Termination Date.
The total payments made in respect of the Insured for such condition both before and afterthe Termination Date will never exceed the Maximum Benefit.
After this "Extension of Benefits" provision has been exhausted, all benefits cease to exist,and under no circumstances will further payments be made.
UMR Care Management should be notified of all Hospital Confinements prior to admission.
1. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATION:
The patient, Physician or Hospital should telephone 1-877-295-0720 at least fiveworking days prior to the planned admission.
2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS:
patient's representative, Physician or Hospital should telephone 1-877-295-0720within two working days of the admission to provide notification of any admission dueto Medical Emergency.
UMR Care Management is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00
p.m. C.S.T., Monday through Friday. Calls may be left on the Customer Service Department's
voice mail after hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise
payable under the policy; however, pre-notification is not a guarantee that benefits will be
paid.
Schedule of Medical Expense Benefits
Injury and Sickness
Up to $250,000 Maximum Benefit (For each Injury or Sickness)
The policy provides benefits for 100% of Usual and Customary Charges incurred by anInsured Person for loss due to a covered Injury or Sickness up to the Maximum Benefit of$250,000 for each Injury or Sickness.
Usual & Customary Charges are based on data provided by FAIR Health, Inc. using the90th percentile based on location of provider.
Benefits will be paid up to the Maximum Benefit for each service as scheduled below.
Covered Medical Expenses include: U&C = Usual & Customary Charges Room & Board Expense, daily semi-private room rate; and U&C
general nursing care provided by the Hospital.
Hospital Miscellaneous Expenses, such as the cost of U&C
the operating room, laboratory tests, x-ray examinations,
anesthesia, drugs (excluding take home drugs) or
medicines, therapeutic services, and supplies. In computing
the number of days payable under this benefit, the date of
admission will be counted, but not the date of discharge.
Surgeon's Fees, in accordance with data provided by
FAIR Health, Inc. If two or more procedures are performedthrough the same incision or in immediate succession atthe same operative session, the maximum amount paid willnot exceed 50% of the second procedure and 50% of allsubsequent procedures.
30% of Surgery Allowance Anesthetist, professional services administered in
connection with inpatient surgery.
Registered Nurse's Services, private duty nursing care.
Physician's Visits, benefits are limited to one visit per day
and do not apply when related to surgery.
Pre-Admission Testing, payable within 7 working days
prior to admission.
Mental or Nervous Conditions
Paid as any other Sickness Surgeon's Fees, in accordance with data provided by FAIR U&C
Health, Inc. If two or more procedures are performed
through the same incision or in immediate succession at the
same operative session, the maximum amount paid will not
exceed 50% of the second procedure and 50% of all
subsequent procedures.
Day Surgery Miscellaneous, related to scheduled surgery U&C
performed in a Hospital, including the cost of the operating
room; laboratory tests and x-ray examinations, including
professional fees; anesthesia; drugs or medicines; and
supplies. Usual and Customary Charges for Day Surgery
Miscellaneous are based on the Outpatient Surgical Facility
Charge Index.
30% of Surgery Allowance professional services administered in U&C connection with outpatient surgery.
Physician's Visits, benefits are limited to one visit per day. U&C
Benefits for Physician's Visits do not apply when related to
surgery or Physiotherapy.
Physiotherapy/ Occupational Therapy, benefits are U&C
limited to one visit per day. Review of Medical Necessity will
be performed after 12 visits per Injury or Sickness.
Medical Emergency Expenses, use of the emergency U&C
room and supplies. Treatment must be rendered within 72
hours from time of Injury or first onset of Sickness.
Diagnostic X-ray & Laboratory Services
Tests & Procedures, diagnostic services and medical U&C
procedures performed by a Physician, other than Physician's
Visits, Physiotherapy, X-Rays and Lab Procedures.
Injections, when administered in the Physician's office and U&C
charged on the Physician's statement.
Prescription Drugs, UnitedHealthcare Network Pharmacy, $1,500 max
$0 copay per prescription tier 1, tier 2, tier 3 / up to a 31 day (Per Policy Year)
supply per prescription. Out-of-Network prescription drugspaid at 100% actual billed charges, $0 Deductible perprescription up to a 31 day supply, $1,500 maximum PerPolicy Year combined in and out of network. Diabetic insulinand supplies are not subject to the $1,500 prescription drugmaximum benefit. See Benefits for Diabetes. Mental or Nervous Conditions
Paid as any other Sickness Ambulance Services, when medically necessary transport Maximum allowable rate
to a Hospital.
established by theDepartment of PublicHealth Durable Medical Equipment, a written prescription must U&C
accompany the claim when submitted. Replacement
equipment is not covered.
Alcoholism / Drug Abuse
See Benefit for Treatmentof Mental or NervousConditions Consultant Physician Fees, when requested and U&C
approved by the attending Physician.
Dental Treatment, made necessary by Injury to Sound, U&C
Natural Teeth; Exception: See Benefits for In-patient Dental
Services.
Maternity & Complications of Pregnancy
Paid as any other Sickness Paid as any other Injury Home Health Care
See Benefits for HomeHealth Care Preventive Care, Preventive Care benefits are based on U&C
guidelines from UnitedHealthcare, the U.S. Preventive
Services Task Force and recommendations of the National
Immunizations Program of the Centers for Disease Control
Prevention, except as specifically provided in the Mandated
Benefit.
Urgent Care Clinic Fee, Benefits are limited to the Urgent U&C
Care Clinic fee billed by the Urgent Care Clinic/Hospital. All
other services rendered during the visit are payable as
specified in the Schedule of Benefits.
This policy does not cover routine, preventive or screening examinations or testing unless
Medical Necessity is established based on medical records. The following maternity routine
tests and screening exams will be considered if all other policy provisions have been met:
Initial screening at first visit – Pregnancy test: Urine human chorionic gonatropin (HCG),
Asymptomatic bacteriuria: Urine culture, Blood type and Rh antibody, Rubella, Pregnancy-
associated plasma protein-A (PAPPA) (first trimester only), Free beta human chorionic
gonadotrophin (hCG) (first trimester only), Hepatitis B: HBsAg, Pap smear, Gonorrhea: Gc
culture, Chlamydia: chlamydia culture, Syphilis: RPR, HIV: HIV-ab, and Coombs test; Each
visit – Urine analysis; Once every trimester – Hematocrit and Hemoglobin; Once during
first trimester – Ultrasound; Once during second trimester – Ultrasound (anatomy
scan); Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen test Alpha-fetoprotein
(AFP), Estriol, hCG, inhibin-a; Once during second trimester if age 35 or over -
Amniocentesis or Chorionic villus sampling (CVS); Once during second or third
trimester – 50g Glucola (blood glucose 1 hour postprandial); and Once during third
trimester - Group B Strep Culture. Pre-natal vitamins are not covered. For additional
information regarding Maternity Testing, please call the Company at 1-800-767-0700.
UnitedHealthcare Network Pharmacy Benefits
Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL)
when dispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supply
limits and copayments that vary depending on which tier of the PDL the outpatient drug is
listed. There are certain Prescription Drugs that require your Physician to notify us to verify
their use is covered within your benefit.
Prescription Drugs which require notification are:
Actiq, Anzemet, Avita-Penderm, Avodart, Copegus, Differin-Gladerma, Diflucan, Elidel,
Emend, Genotropin, Humatrope, Increlex, Infergen, Intron-A, Iplex, Kytril, Lamisil, Lotronex,
Norditropin, Nutropin, Nutropin AQ, Nutropin Depot, PEG-Intron, Pegasys, Proscar, Protopic,
Protropin, Provigil, Raptiva, Regranex, Relenza, Retin-A, Retin-A Micro Ortho, Rebetol,
Rebetron, Restasis, Revatio, Roferon, Sporanox, Saizen, Serostim, Tamiflu, Tazorac, Tracleer,
Ventavis, Wellbutrin SR, Wellbutrin XL, Zelnorm, Zofran, Zorbtive.
You are responsible for paying the applicable copayments. Your copayment is determined
by the tier to which the Prescription Drug Product is assigned on the PDL. Tier status may
change periodically and without prior notice to you. Please call 877-417-7345 for the most
up-to-date tier status.
$0 copay per prescription or refill for tier 1 Prescription Drug up to 31 day supply.
$0 copay per prescription or refill for tier 2 Prescription Drug up to 31 day supply.
$0 copay per prescription or refill for tier 3 Prescription Drug up to 31 day supply.
Your maximum allowed benefit is $1,500 Per Policy Year.
Diabetic insulin and supplies are not subject to the $1,500 Prescription Drugs maximum
benefit but are subject to the overall Policy Maximum Benefit.
Please present your ID card to the network pharmacy when the prescription is filled. If you
do not present the card, you will need to pay for the prescription and then submit a
reimbursement form for prescriptions filled at a network pharmacy along with the paid
receipt in order to be reimbursed. To obtain reimbursement forms, or for information about
mail-order prescriptions or network pharmacies, please visit www.uhcsr.com and log in to
your online account or call 877-417-7345.
When prescriptions are filled at pharmacies outside the network, the Insured must pay for
the prescriptions out-of-pocket and submit the receipts for reimbursement to
UnitedHealthcare StudentResources, P.O. Box 809025, Dallas, TX 75380-9025. See the
Schedule of Benefits for the benefits payable at out-of-network pharmacies.
Additional Exclusions
In addition to the policy Exclusions and Limitations, the following Exclusions apply toNetwork Pharmacy Benefits: 1. Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which exceeds the supply limit.
2. Experimental or Investigational Services or Unproven Services and medications; medications used for experimental indications and/or dosage regimens determinedby the Company to be experimental, investigational or unproven.
3. Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration and requires a Prescription Orderor Refill. Compounded drugs that are available as a similar commercially availablePrescription Drug Product. Compounded drugs that contain at least one ingredientthat requires a Prescription Order or Refill are assigned to Tier-3.
4. Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed, unless the Company has designated theover-the counter medication as eligible for coverage as if it were a Prescription DrugProduct and it is obtained with a Prescription Order or Refill from a Physician.
Prescription Drug Products that are available in over-the-counter form or comprisedof components that are available in over-the-counter form or equivalent, unless aMedical Necessity. Certain Prescription Drug Products that the Company hasdetermined are Therapeutically Equivalent to an over-the-counter drug, unlessMedical Necessity. Such determinations may be made up to six times during acalendar year, and the Company may decide at any time to reinstate Benefits for aPrescription Drug Product that was previously excluded under this provision.
5. Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease, even when used for the treatment of Sickness orInjury, except as required by state mandate.
Network Pharmacy means a pharmacy that has:
• Entered into an agreement with the Company or an organization contracting on our behalf to provide Prescription Drug Products to Insured Persons.
• Agreed to accept specified reimbursement rates for dispensing Prescription Drug • Been designated by the Company as a Network Pharmacy.
Prescription Drug or Prescription Drug Product means a medication, product or device
that has been approved by the U.S. Food and Drug Administration and that can, under
federal or state law, be dispensed only pursuant to a Prescription Order or Refill. A
Prescription Drug Product includes a medication that, due to its characteristics, is
appropriate for self-administration or administration by a non-skilled caregiver. For the
purpose of the benefits under the policy, this definition includes insulin.
Prescription Drug List means a list that categorizes into tiers medications, products or
devices that have been approved by the U.S. Food and Drug Administration. This list is
subject to the Company's periodic review and modification (generally quarterly, but no more
than six times per calendar year). The Insured may determine to which tier a particular
Prescription Drug Product has been assigned through the Internet at www.uhcsr.com or call
Customer Service at 1-877-417-7345.
Benefits for Accidental Ingestion of a Controlled Drug
Benefits will be paid for accidental ingestion or consumption of a controlled drug asrequired by Connecticut statute. When inpatient treatment in a Hospital, whether or notoperated by the State, is required as a result of accidental ingestion or consumption of acontrolled drug, benefits will be paid for the Usual and Customary Charges incurred up toa maximum of 30 days Hospital Confinement. Benefits will be paid for outpatient treatmentresulting from accidental ingestion or consumption of a controlled drug up to a maximumof $500 for any one accident.
Benefits for Hypodermic Needles or Syringes
Benefits will be paid for the Usual and Customary Charges incurred for hypodermic needlesor syringes prescribed by a licensed Physician for the purpose of administering medicationsfor any Injury or Sickness, provided such medications are covered under the policy. Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Reconstructive Breast Surgery
Benefits will be paid for the Usual and Customary Charges incurred for reconstructivesurgery on each breast on which a mastectomy has been performed, and reconstructivesurgery on a nondiseased breast to produce a symmetrical appearance. Reconstructivesurgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplastyand mastopexy.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Home Health Care
Benefits will be paid as specified below for Injury or Sickness for home health care to
residents in Connecticut.
Benefits payable shall be limited to eighty visits in any calendar year or in any continuous
period of twelve months for each Insured, except in the case of an Insured diagnosed by a
Physician as terminally ill with a prognosis of six months or less to live, the yearly benefit for
medical social services shall not exceed two hundred dollars ($200.00). Each visit by a
representative of a home health agency shall be considered as one home health care visit;
four hours of home health aide service shall be considered as one home health care visit.
Home health care benefits are subject to an annual Deductible of fifty dollars ($50.00) for
each Insured and will be subject to a coinsurance provision of not less than seventy-five
percent (75%) of the Usual and Customary Charges for such services. If an Insured is
eligible for home health care coverage under more than one policy, the home health care
benefits shall only be provided by that Policy which would have provided the greatest
benefits for hospitalization if the person had remained or had been hospitalized.
"Home health care" means the continued care and treatment of a covered person who is
under the care of a Physician if:
(1) continued hospitalization would otherwise have been required if home health care was not provided, except in the case of an Insured diagnosed by a Physician as terminallyill with a prognosis of six months or less to live, and, (2) the plan covering the home health care is established and approved in writing by such Physician within seven days following termination of a hospital confinement as aresident inpatient for the same or a related condition for which the Insured washospitalized, except that in the case of an Insured diagnosed by a Physician asterminally ill with a prognosis of six months or less to live, such plan may be soestablished and approved at any time irrespective of whether such Insured was soconfined or, if such Insured was so confined, irrespective of such seven-day period,and (3) such home health care is commenced within seven days following discharge, except in the case of a covered person diagnosed by a Physician as terminally ill with aprognosis of six months or less to live.
Home health care shall be provided by a home health agency. "Home health agency"
means an agency or organization which meets each of the following requirements:
(1) It is primarily engaged in and is federally certified as a home health agency and duly licensed by the appropriate licensing authority to provide nursing and othertherapeutic services.
(2) Its policies are established by a professional group associated with such agency or organization, including at least one Physician and at least one Registered Nurse, togovern the services provided.
(3) It provides for full-time supervision of such services by a Physician or by a Registered (4) It maintains a complete medical record on each patient.
(5) It has an administrator.
Home health care shall consist of, but shall not be limited to, the following: (1) Part-time or intermittent nursing care by a Registered Nurse or by a licensed practical nurse under the supervision of a Registered Nurse, if the services of a RegisteredNurse are not available; (2) Part-time or intermittent home health aide services, consisting primarily of patient care of a medical or therapeutic nature by other than a Registered Nurse or licensedpractical nurse; (3) Physical, occupational or speech therapy;(4) Medical supplies, drugs and medicines prescribed by a Physician and laboratory services to the extent such charges would have been covered under the Policy orcontract if the Insured had remained or had been confined in the Hospital; (5) Medical social services provided to or for the benefit of a covered person diagnosed by a Physician as terminally ill with a prognosis of six months or less to live. "Medicalsocial services" mean services rendered, under the direction of a Physician by aqualified social worker, including but not limited to: (A) assessment of the social, psychological and family problems related to or arising out of such covered person's illness and treatment; (B) appropriate action and utilization of community resources to assist in resolving such (C) participation in the development of the overall plan of treatment for such Insured.
Benefits shall be subject to all other limitations and provisions of the policy.
Benefits for Mammography and Comprehensive Ultrasound Screening
Benefits will be paid the same as any other Covered Medical Expenses as shown on theSchedule of Benefits for mammographic examinations to any woman insured under thispolicy which are equal to the following requirements: 1) a baseline mammogram for anywoman who is thirty-five to thirty-nine years of age, inclusive; and 2) a mammogram everyyear for any woman who is forty years of age or older. Additional benefits will be provided for comprehensive ultrasound screening of an entirebreast or breasts if a mammogram demonstrates heterogeneous or dense breast tissuebased on the Breast Imaging Reporting and Data System established by the AmericanCollege of Radiology or if a woman is believed to be at increased risk for breast cancer dueto family history or prior personal history of breast cancer, positive genetic testing or otherindications as determined by a woman's Physician or advanced practice Registered Nurse.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Ostomy Appliances and Supplies
Benefits will be paid for the Usual and Customary Charges for Medically Necessaryappliances and supplies relating to an ostomy including, but not limited to, collectiondevices, irrigation equipment and supplies, skin barriers and skin protectors up to amaximum benefit of $1,000 per Policy Year. "Ostomy" shall include colostomy, ileostomy and urostomy. Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Autism Spectrum Disorders
Benefits will be paid the same as any other Sickness for physical therapy, speech therapy,and occupational therapy services for the treatment of Autism Spectrum Disorders, as setforth in the most recent edition of the American Psychiatric Association's "Diagnostic andStatistical Manual of Mental Disorders".
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Treatment of Tumors and Leukemia
Benefits will be paid the same as any other Sickness for the surgical removal of tumors andfor treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, costof any non-dental prosthesis, including any maxillofacial prosthesis used to replaceanatomic structures lost during treatment for head and neck tumors or additionalappliances essential for the support of such prosthesis and outpatient chemotherapyfollowing surgical procedures in connection with the treatment of tumors, and a wig ifprescribed by a licensed oncologist for a patient who suffers hair loss as a result ofchemotherapy.
Benefits per policy year shall be at least $1,000 for the removal of any breast implant,$500 for the surgical removal of tumors, $500 for reconstructive surgery, $500 foroutpatient chemotherapy and $300 for prosthesis, except that for purposes of the surgicalremoval of breasts due to tumors the yearly benefit for prosthesis shall be at least $300 foreach breast removed, and $350 for a wig.
If the policy provides benefits for Prescription Drugs, benefits will be provided for prescribedorally administered anticancer medications on a basis that is no less favorable thanintravenously administered anticancer medications.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Prostate Cancer Testing
Benefits will be paid the same as any other Sickness for laboratory and diagnostic tests,including, but not limited to, prostate specific antigen (PSA) tests to screen for prostatecancer for Insureds who are symptomatic, whose biological father or brother has beendiagnosed with prostate cancer, and for all Insureds fifty (50) years of age or older.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Colorectal Cancer Screening
Benefits will be paid the same as any other Sickness for colorectal cancer screening,including, but not limited to: (1) an annual fecal occult blood test, and (2) colonoscopy,flexible sigmoidoscopy or radiologic imaging, in accordance with the recommendationsestablished by the American College of Gastroenterology, after their consultation with theAmerican Cancer Society, based on the ages, family histories and frequencies provided inthe recommendations. Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Cancer Clinical Trial
Benefits will be paid the same as any other Sickness for the medically necessary treatmentfor Routine Patient Care Costs associated with Cancer Clinical Trials. Benefits are subject to all Deductible, copayment, terms, conditions, restrictions, Exclusionsand Limitations of the policy.
A detailed description of the benefits and restrictions for Cancer Clinical Trials is availablein the Master Policy on file at the school or by calling the Company at 1-800-767-0700.
Benefits for Diabetes
Benefits will be paid the same as any other Sickness for the treatment of insulin-dependentdiabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes. Suchcoverage shall include Medically Necessary equipment, in accordance with the InsuredPerson's treatment plan, drugs and supplies prescribed by a Physician.
If the policy contains a Prescription Drugs maximum benefit, diabetic insulin and suppliesshall not be subject to the Prescription Drugs maximum benefit specified in the Scheduleof Benefits. Benefits shall be subject to all other Deductible, copayments, coinsurance,limitations, or any other provisions of the policy.
Benefits for Postpartum Care
If an Insured and Newborn Infant are discharged from inpatient care less than forty-eighthours after a vaginal delivery or less than ninety-six hours after a cesarean delivery, benefitswill be provided on the same basis as any other Covered Medical Expenses as shown onthe Schedule of Benefits for a follow-up visit within forty-eight hours of discharge and anadditional follow-up visit within seven days of discharge. Any decision to shorten the lengthof inpatient stay to less than forty-eight hours after a vaginal delivery or ninety-six hoursafter a cesarean delivery shall be made by the Physician after conferring with the Insured. Follow-up services shall include, but not be limited to, physical assessment of the Newborn,parent education, assistance and training in breast or bottle feeding, assessment of thehome support system and the performance of any Medically Necessary and appropriateclinical tests. Such services shall be consistent with protocols and guidelines developed byattending providers or by national pediatric, obstetric and nursing professional organizationsfor these services and shall be provided by qualified health care personnel trained inpostpartum maternal and Newborn pediatric care.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Amino Acid Modified Preparations and
Low Protein Modified Food Products
Benefits will be paid the same as any other outpatient Prescription Drug for Amino AcidModified Preparations and Low Protein Modified Food Products for the treatment ofInherited Metabolic Diseases if the Amino Acid Modified Preparations or Low ProteinModified Food Products are prescribed for the therapeutic treatment of Inherited MetabolicDiseases and are administered under the direction of a Physician.
If the policy does not provide benefits for outpatient Prescription Drugs, benefits will beprovided subject to the policy maximum benefit including any Deductible, copayment orcoinsurance requirements.
"Inherited metabolic disease" means (A) disease for which newborn screening is requiredunder Connecticut Statute Title 38a, Chapter 700c, Section 19a-55, and (B) Cystic Fibrosis.
"Low protein modified food product: means a product formulated to have less than onegram of protein per serving and intended for the dietary treatment of an inherited metabolicdisease under the direction of a physician.
"Amino acid modified preparation" means a product intended for the dietary treatment ofan inherited metabolic disease under the direction of a Physician.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Lyme Disease Treatment
Benefits will be paid the same as any other Sickness for Lyme disease treatment includingnot less than thirty days of intravenous antibiotic therapy, sixty days of oral antibiotic therapy,or both, and shall provide benefits for further treatment if recommended by a Physician.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Isolation Care and Emergency Services
Benefits will be paid the same as any other Injury or Sickness for isolation care andemergency services provided by the state's mobile field Hospital. Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Diabetic Outpatient Self-Management Training
Benefits will be paid the same as any other Sickness for outpatient self-managementtraining for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestationaldiabetes and non-insulin-using diabetes if the training is prescribed by a Physician. Outpatient self-management training includes, but is not limited to, education and medicalnutrition therapy. Diabetes self-management training shall be provided by a Physician, asdefined in the Policy, trained in the care and management of diabetes and authorized toprovide such care within the scope of the Physician's practice.
Covered Medical Expenses shall include: 1) Initial training visits provided to an Insured after the Insured is initially diagnosed with 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 equipmentand supplies for the treatment of diabetes, up to a maximum of ten hours.
2) Training and education that is Medically Necessary as a result of a subsequent diagnosis by a Physician of a significant change in the Insured's symptoms orcondition which requires modification of the Insured's program of self-managementof diabetes, up to a maximum of four hours.
3) Training and education that is Medically Necessary because of the development of new techniques and treatment for diabetes up to a maximum of four hours.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Inpatient Dental Services
Benefits will be paid the same as any other Sickness for general anesthesia, nursing andrelated Hospital services provided in conjunction with inpatient, outpatient or one day dentalservices if the following conditions are met: 1) The anesthesia, nursing and related Hospital services are deemed Medically Necessary by the treating Physician.
2) The Insured is either a) a person who is determined by a Physician to have a dental condition of significant dental complexity that it requires certain dental proceduresto be performed in a Hospital, or b) a person who has a developmental disability, asdetermined by a Physician, that places the person at serious risk. The expense of anesthesia, nursing and related Hospital services shall be deemed aCovered Medical Expense and shall not be subject to any limits on dental benefits in thePolicy.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Treatment of Craniofacial Disorders
Benefits will be paid the same as any other Sickness for medically necessary orthodonticprocesses and appliances for the treatment of craniofacial disorders for Insureds eighteenyears of age or younger. The processes and appliances must be prescribed by a craniofacialteam recognized by the American Cleft Palate-Craniofacial Association. No benefits areprovided for cosmetic surgery.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Mental or Nervous Conditions
Benefits will be paid the same as any other Sickness for the diagnosis and treatment ofMental or Nervous Conditions.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Pain Management
Benefits will be paid the same as any other Sickness for Pain treatment ordered by a PainManagement Specialist, which may include all means Medically Necessary to make adiagnosis and develop a treatment plan including the use of necessary medications andprocedures.
"Pain" means a sensation in which a person experiences severe discomfort, distress orsuffering due to provocation of sensory nerves, and "pain management specialist" means aPhysician who is credentialed by the American Academy of Pain Management or who is aboard-certified anesthesiologist, neurologist, oncologist or radiation oncologist withadditional training in pain management.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Infertility Treatment
Benefits will be paid the same as any other Sickness for an Insured Person for themedically necessary expenses of the diagnosis and treatment of Infertility, including, but notlimited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryolavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer andlow tubal ovum transfer. Such infertility treatment must be performed at facilities thatconform to the standards and guidelines developed by the American Society ofReproductive Medicine or the Society of Reproductive Endocrinology and Infertility. For the purposes of this section "Infertility" means the condition of a presumably healthyindividual who is unable to conceive or produce conception or sustain a successfulpregnancy during a one year period.
Benefits are subject to the following limitations: 1) Benefits are available up to the Insured Person's fortieth (40) birthday.
2) Benefits for ovulation induction are subject to a lifetime limit of four (4) cycles.
3) Benefits for intrauterine insemination are subject to a lifetime limit of three (3) cycles.
4) Benefits for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer, and tubal ovum transfer are subject to a lifetime limit of two (2) cycles, withnot more than two (2) embryo implantations per cycle.
5) Benefits for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer are payable only to those Insured Persons who: a) Have been unable to conceive or produce conception or sustain a successful pregnancy through less expensive and medically viable infertility treatment orprocedures covered by this policy. However benefits will not be denied on this basisfor any Insured Person who forgoes a particular infertility treatment or procedure ifthe Insured Person's Physician determines that such treatment or procedure islikely to be unsuccessful.
b) Have been covered under the school's student insurance policy for at least 12 c) Provide disclosure of any previous infertility treatment or procedures for which such Insured Person received coverage under a different health insurance policy.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Benefits for Epidermolysis Bullosa Treatment
Benefits will be paid for the Usual and Customary Charges for wound-care supplies thatare Medically Necessary for the treatment of Epidermolysis Bullosa provided such benefitsare administered under the direction of a Physician.
"Epidermolysis Bullosa" is a genetic disorder caused by a mutation in the keratin gene. Thedisorder is characterized by the presence of extremely fragile skin and recurrent blisterformation, resulting from minor mechanical friction or trauma.
Benefits shall be subject to all Deductible, copayments, coinsurance, limitations, or anyother provisions of the policy.
Injury means accidental bodily injuries sustained by the Insured Person which: 1) are the
direct cause, independent of disease or bodily infirmity or any other cause; 2) are treated
by a Physician within 30 days after the date of accident; and occurs while this policy is in
force, subject to the policy Pre-existing Condition provisions. Covered Medical Expenses
incurred as a result of an injury that occurred prior to this policy's Effective Date will be
considered a Sickness under this policy, subject to the policy Pre-existing Condition
provisions.
Sickness means sickness or disease of the Insured Person which causes loss while the
Insured Person is covered under this policy, subject to the policy Pre-existing Condition
provisions. All related conditions and recurrent symptoms of the same or a similar condition
will be considered one sickness. Covered Medical Expenses incurred as a result of an Injury
that occurred prior to this policy's Effective Date will be considered a sickness under this policy.
Totally Diabled means a condition of a Named Insured which, because of Sickness or
Injury, renders the Insured unable to actively attend class.
Usual and Customary Charges means a reasonable charge which is: 1) usual and
customary when compared with the charges made for similar services and supplies; and 2)
made to persons having similar medical conditions in the locality where service is rendered.
No payment will be made under this policy for any expenses incurred which in the judgment
of the Company are in excess of Usual and Customary Charges.
Exclusions And Limitations
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from;or b) treatment, services or supplies for, at, or related to: 1. Acupuncture, allergy testing; 2. Biofeedback;3. Circumcision;4. Congenital conditions, except as specifically provided for Newborn or adopted Infants;5. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adopted children; 6. Dental treatment, except as specifically provided in the Policy; 7. Elective Surgery or Elective Treatment; 8. Elective abortion;9. Eye examinations, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses; except when due to a disease process; 10. Foot care including: care of corns, bunions (except capsular or bone surgery) and 11. Hearing examinations or hearing aids or other treatment for hearing defects and problems. "Hearing defects" means any physical defect of the ear which does or canimpair normal hearing, apart from the disease process; 12. Hirsutism; alopecia; 13. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury, except asspecifically provided in the policy; 14. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 15. Lipectomy;16. Organ transplants; 17. Participation in a riot, civil disorder or a felony, except when Injury occurs when the Insured Person has an elevated blood alcohol content or when under the influence ofintoxication liquor or any drug or both. Participation means to voluntarily take a part orshare with others assembled together in some activity. Riot means a violent publicdisturbance of the peace by a number of persons assembled together; 18. Prescription Drugs, services or supplies as follows, except as specifically provided in a) Therapeutic devices or appliances, including: hypodermic needles and syringes, except for hypodermic needles or syringes prescribed by a Physician for thepurpose of administering medications for medical conditions, provided suchmedications are covered under the policy, support garments and other non-medicalsubstances; b) Immunization agents, biological sera, blood or blood products administered on an outpatient basis; c) Drugs labeled, "Caution-limited by federal law to investigational use" or experimental drugs except for drugs for the treatment of cancer that have not beenapproved by the Federal Food and Drug Administration, provided the drug isrecognized for treatment of the specific type of cancer for which the drug has beenprescribed in one of the following established reference compendia: (1) The U.S.
Pharmacopeia Drug Information Guide for the Health Care Professional (USP DI);(2) The American Medical Association's Drug Evaluations (AMA DE); or (3) TheAmerican Society of Hospital Pharmacist's American Hospital Formulary ServiceDrug Information (AHFS-DI); d) Products used for cosmetic purposes;e) Drugs used to treat or cure baldness; anabolic steroids used for body building;f) Anorectics- drugs used for the purpose of weight control;g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; except as specifically provided in theBenefits for Infertility Treatment; h) Growth hormones; ori) Refills in excess of the number specified or dispensed after one (1) year of date of the prescription; 19. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for thepurpose or with the intent of inducing conception; except as specifically provided inthe Benefits for Infertility Treatment; 20. Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery; except asspecifically provided in the policy; 21. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specificallyprovided in the policy; 22. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia, except as specifically provided in the Benefits for Treatment of CraniofacialDisorders; 23. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularlyscheduled flight of a commercial airline; 24. Sleep disorders;25. Unless specifically covered under Benefits for Mental or Nervous Conditions, Injury resulting from suicide or attempted suicide while sane or insane (including intentionaldrug overdose); or intentionally self-inflicted Injury; 26. Supplies, except as specifically provided in the policy; 27. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the Benefits forReconstructive Breast Surgery and Benefits for Treatment of Tumors and Leukemia; 28. Treatment in a Government hospital for which the Insured is not charged, unless there is a legal obligation for the Insured Person to pay for such treatment; 29. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered); and 30. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat, and treatment of eating disorders such as bulimia andanorexia, except as specifically provided in the policy. Exception: benefits will be providedor the treatment of dehydration and electrolyte imbalance associated with eatingdisorders.
The Insurer will furnish the Insured the necessary forms for filing proof of loss. Claim formsmay be obtained at the Company, P.O. Box 809025, Dallas, Texas 75380-9025.
If the person making claim does not receive the necessary claim forms before the expirationof 15 days after first requesting such forms, the Insured Person shall be deemed to havecomplied with the requirements as to the proof of loss upon submitting to the Insured within90 days written proof covering the occurrence, character and extent of the loss for whichclaim is made.
Written proof of loss must be submitted to the Company at P.O. Box 809025, Dallas, Texas75380-9025 within 90 days after expense is incurred, or as soon thereafter as reasonablypossible.
The Company, at its own expense, shall have the right and opportunity to examine theInsured as often as it may reasonably require and also may make an autopsy in case ofdeath if not prohibited by law. Failure of an insured to present himself or herself forexamination by a Physician when requested shall authorize the Company to: 1) withholdany payment of Covered Medical Expenses until such examination is performed andPhysician's report received; and 2) deduct from any amounts otherwise payable hereunderany amount for which the Company has been obligated to pay a Physician retained by theCompany to make an examination for which the insured failed to appear. Said deductionshall be made with the same force and effect as a Deductible herein defined.
All benefits payable under the Policy will be paid upon receipt of due written proof of loss.
All benefits are payable to the Insured or his designated beneficiary or beneficiaries or tohis estate, except that if the person insured be a minor, such benefits may be made payableto his parents, guardian or other person actually supporting him. Subject to any writtendirection of the Insured, all or a portion of any benefits payable under the Policy may be paiddirectly to the Hospital, Physician or person rendering the service or treatment.
No action shall be brought under the Policy prior to the expiration of 60 days after filingwritten proof of loss and no action may be brought after 3 years from the date within whichproof of loss is required by the Policy.
Scholastic Emergency Services:
Global Emergency Medical Assistance
If you are a student insured with this insurance plan, you are eligible for Scholastic
Emergency Services (SES). The requirements to receive these services are as follows:
International Students: You are eligible to receive SES worldwide, except in your home
country.
Domestic Students: You are eligible for SES when 100 miles or more away from your
campus address and 100 miles or more away from your permanent home address or while
participating in a Study Abroad program.
SES includes Emergency Medical Evacuation and Return of Mortal Remains that meet the
US State Department requirements. The Emergency Medical Evacuation services are not
meant to be used in lieu of or replace local emergency services such as an ambulance
requested through emergency 911 telephone assistance. All SES services must be
arranged and provided by SES, Inc.; any services not arranged by SES, Inc. will not be
considered for payment.
Key Services include:
* Medical Consultation, Evaluation and Referrals * Prescription Assistance* Foreign Hospital Admission Guarantee * Critical Care Monitoring * Emergency Medical Evacuation * Return of Mortal Remains * Medically Supervised Repatriation * Transportation to Join Patient * Emergency Counseling Services * Interpreter and Legal Referrals * Lost Luggage or Document Assistance* Care for Minor Children Left Unattended Due to a Medical Incident Please visit your school's insurance coverage page at www.uhcsr.com for the SES Global
Emergency Assistance Services brochure which includes service descriptions and program
exclusions and limitations.
To access services please call:
(877) 488-9833 Toll-free within the United States
(609) 452-8570 Collect outside the United States
Services are also accessible via e-mail at [email protected].
When calling the SES Operations Center, please be prepared to provide:
1. Caller's name, telephone and (if possible) fax number, and relationship to the patient;2. Patient's name, age, sex, and Reference Number;3. Description of the patient's condition;4. Name, location, and telephone number of hospital, if applicable;5. Name and telephone number of the attending physician; and6. Information of where the physician can be immediately reached.
SES is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan andare subject to the policy limits of your health coverage. All assistance services must bearranged and provided by SES, Inc. Claims for reimbursement of services not provided bySES will not be accepted. Please refer to your SES brochure or Program Guide atwww.uhcsr.com for additional information, including limitations and exclusions pertaining tothe SES program.
In the event of Injury or Sickness, students should: 1) Report at once to the Student Health Service or Infirmary for treatment, or when not in school, to the nearest Physician or Hospital.
2) Secure a Company claim form from the Student Health Service or from the address below, fill out the form completely, attach all medical and hospital bills and mail tothe address below.
3) File claim within 30 days of Injury or first treatment for a Sickness. Bills must be received by the Company within 90 days of service. Bills submitted after one yearwill not be considered for payment except in the absence of legal capacity.
The Plan is Underwritten by:
UnitedHealthcare Insurance Company Submit all Claims or Inquiries to:
UnitedHealthcare StudentResources
P.O. Box 809025
Dallas, Texas 75380-9025
1-888-455-9402
UnitedHealthcare StudentResources
805 Executive Center Drive West, Suite 220
St. Petersburg, FL 33702
Please keep this Certificate as a general summary of the insurance. The Master Policy onfile at the school contains all of the provisions, limitations, exclusions and qualifications ofyour insurance benefits, some of which may not be included in this Certificate.
The Master Policy is the contract and will govern and control payment of benefits.
This Certificate is based on Policy

Source: http://web.suffieldacademy.org/forms/summer2012/INSURANCE.pdf