Health Insurance
Student Accident and Sickness Insurance
This plan will pay up to $10,000 in covered expenses per condition.
Basic Medical Expense Benefit Schedule
The following benefits are provided for incurred eligible medical expenses up to $500 for a covered accident or covered sickness. Benefits will be provided for medical expenses incurred as an inpatient or outpatient, as a result of a covered accident or sickness, until the termination date, or any extension of benefits of the Policy. The first $300 of covered expense incurred will be processed on a primary basis regardless of any other insurance. If expenses exceed $300, the claim will then be paid on an excess basis, if other insurance or medical service plans are involved.
| Benefits | For Accidents and Sickness |
| Hospital Room & Board Up to the semi-private room rate |
100% of Usual & Customary (U & C) |
| Miscellaneous Hospital Expense including: Anesthesia, use of operating room, nurse services of the LPN or RN, laboratory tests, X-ray examinations, prescription drugs and medications, casts & temporary surgical appliances. |
100% of U & C |
| Surgical Expense &nbap;(In- or Out-patient) |
100% 0f U & C |
| Anesthetist | 33% of Surgery Allowance |
| Miscellaneous Outpatient Expense including: X-rays, laboratory tests, and services & supplies prescribed by the attending physician |
*$100 ER co-pay (applicable only if seen Diagnostic in ER) then 100% of U & C |
| Physician's Fees | 100% of U & C |
| Dental Treatment for accidental injury to sound, natural teeth, and removal of wisdom teeth | 100% of U & C up to $200 per tooth |
| Ambulance Expense for Emergency Transportation | 100% of U & C |
| Mental & Nervous Disorders | |
Mental Health Care
|
Same as any other Sickness, up to $2,000 Same as any other Sickness. |
Substance Abuse Disorders
|
Same as any other Sickness, up to $1,500 Same as any other Sickness. |
| Intercollegiate Sports | 100% of U & C up to $500 |
| Maternity | Same as any other Sickness. |
| Annual Physical | 100% of U & C up to $200 |
| STD Testing | 100% of U & C up to $50 |
*There is a $100 co-payment for Emergency Room visits only. To copay will be waived if you are hospital admitted or for intercollegiate sports injuries.
**Outpatient Substance Abuse benefits are covered under the Basic Benefits of the Policy up to $1,500; Outpatient Mental Health Care benefits are covered under the Basic Benefits of the Policy up to $2,000 as provided by the benefits mandated by the State of Maine.
Supplemental Expense Benefit
After incurring $500 in expenses for a covered accident or covered sickness which is payable under the Basic Medical Expense Benefit section above, and a $100 deductible is applied, eligible expenses in excess of $500, are payable at 80% of the Usual and Customary charges for covered accidents and sicknesses, up to a maximum of $9,500 in additional benefits. Expenses must be incurred during the Policy term. Outpatient Mental Health Care and Substance Abuse Benefits are not covered under the Supplemental Expense Benefit, except Severe Mental Illness as defined in the Policy.
Disclaimer
This is not the policy. Rather it is a brief description of the benefits of the Policy. For clarification on further benefits, provisions, exclusions, and procedures of this Policy, please contact the Director of Health Services.