The Reliance Standard Life Insurance Company offers a reasonably priced optional student accident insurance plan that can help parents pay for some of the medical expenses due to accidents that may occur during school hours, during school sports (except varsity tackle football) and while away from school, including the weekends and all vacation periods including the summer months. The one-time cost for FULL TIME / 24-HOUR AT SCHOOL AND AT HOME protection is available for a one-time payment of $40.00 for coverage while at school, at home, during vacation periods including the summer months. Or, parents can purchase a $15 plan that will cover students only while they are in attendance at school during school classes and school sports (except varsity tackle football). Families that already have primary insurance may be able to utilize these plans as a supplement to help pay some of their out-of-pocket expenses due to high deductibles or copay amounts. Families without any insurance protection should consider purchasing one of these optional plans to help pay for some of their children's medical bills in the event of accidents.
Note: The optional coverage plans are only available to insure students enrolled in grades Pre-Kindergarten through grade 12 in the school district. The coverage options are not available to high school graduates, college students, children that attend other school districts or adults. A policy summary of the optional insurance plans benefits, terms, provisions and exclusions are outlined below. The policy benefits are limited and will not provide full 100% payment for all doctor and hospital billed charges. This optional student insurance plan does not cover students during participation in sports. The school district purchases a group insurance policy that may help cover some of the expenses incurred due to tackle football related injuries. Therefore, the voluntary optional plans explained below do not cover accidents related to the practice or play of tackle football.
OPTION I...The $40 FULL TIME / 24-HOUR AT SCHOOL AND AT HOME ACCIDENT INSURANCE PLAN:
Provides accident insurance protection in the event of accidental injuries that may occur while students are at school during classes, school sports (except varsity tackle football) and other school activities, while at home, away from school, on the weekends, holidays, during vacation periods including the June, July and August summer months…. 24 hours a day, 7 days a week. Coverage is effective through August 31, 2018. This plan has no deductible and pays up to $25,000 per covered accident, subject to the policy terms, limits and exclusions listed below. The plan does not cover tackle football related accidents. COST for FULL TIME / 24-HOUR ACCIDENT INSURANCE PLAN is a one-time single payment of $40.00.
OPTION II...The $15 AT SCHOOL ACCIDENT INSURANCE PLAN: This plan provides coverage only while students are attending school classes, school sports (except varsity tackle football) and other covered school sponsored activities during the regular school term. The AT SCHOOL PLAN does not cover students that may occur while away from school or during participation tackle football or summer league sports. Additional policy limitations and terms are explained below.
SUMMARY OF OPTION I AND OPTION II POLICY BENEFITS
If a covered accidental injury requires treatment and is treated by a licensed physician within 30 days after the date of the covered accident, the plan will pay for necessary hospital, medical, physician's and dental care incurred within one year from the date of the covered accident up to a maximum medical benefit of $25,000 per covered accident, subject to the following specified dollar limits:
Policy Deductible: No deductible. Payment of benefits begin with the first dollar of billed charges.
Non-Surgical Doctor Visits/Consultations: Pays up to $20 for first visit;Pays up to $15 for each necessary follow-up visit
Surgery/Fracture Care (scheduled benefits): Pays up to $1,000 for the reasonable fees based the CRVSX75 publication of physician's fees
Anesthesia Administration Fees: Pays up to 25% of the allowable policy benefit paid to the primary surgeon for all anesthesia administration fees
In-Patient Hospital Expense: Pays up to $250 for each overnight stay of hospital confinement including hospital billed charges for drugs, lab, x-ray, therapy, supplies, operating room, and all other hospital billed charges
Emergency Room Charges: Pays up to $50 for all ER billed charges including miscellaneous supplies, lab, drugs, etc. (separate policy benefits apply to fees charged by attending physicians and for radiological expenses)
Outpatient Hospital charges or Surgi-Center facility charges:(when major surgery is performed on an outpatient, 'same-day surgery' basis)
Pays up to $250 for all Hospital or Surgi-Center facility billed charges
Outpatient X-ray Benefit: Pays up to $50 (includes reading and interpretation fees)
Diagnostic Imaging for MRI/bone scan/CT and other Scans: Pays up to $100 per covered accident (includes reading and interpretation fees)
Out-Patient Therapy/Manipulations/Adjustments:or similar treatment/office visits: Pays up to $15 per daily visit, not to exceed a total of 6 visits per accident
Orthopedic Appliances/Casting/Braces: Pays up to $25
Licensed Ambulance Service: Pays up to $100 for the initial emergency trip by air or ground transport
Take-Home Drugstore Prescriptions: No benefit for drugs
Dental Benefits: Pays up to $100 per injured tooth; (orthodontic procedures & treatment of previously damaged or decayed teeth not covered by the policy)
For any Covered Motor Vehicle Related Injury:The policy will pay up to a maximum benefit of $500 for all medical treatment expenses in the aggregate associated with a covered motor vehicle related injury.
Accidental Death Benefit: Pays $1,000 in the event of death directly related to a covered accident
'IN-HOSPITAL SICKNESS BENEFIT COVERAGE OPTION': The student accident insurance Options I and II listed above provide benefits only for medical expenses resulting from covered accidental injuries. Options I and II do not cover treatment expenses due to illness, sickness or diseases. However, a benefit to cover hospitalization due to illnesses can be added to the FULL TIME 24-HOUR ACCIDENT INSURANCE PLAN. If the 'IN-HOSPITAL SICKNESS' option is purchased and your child is hospitalized due to a covered illness or disease, the insurance will pay up to $500 for each day of overnight hospital billed charges to treat a child’s covered illness or disease. The maximum benefit payable under the 'In-Hospital Sickness Benefit Coverage Option' is $5,000. (The 'In-Hospital Coverage Sickness Benefit Option' does not pay for the services of physicians or other out-patient medical services). Cost to add the 'IN-HOSPITAL SICKNESS BENEFIT': Single payment of $38.00 buys in-hospital sickness coverage through August 31, 2018.
SUMMARY OF STUDENT INSURANCE PLAN LIMITATIONS, TERMS AND EXCLUSIONS
Underwritten by Reliance Standard Life Insurance, 2001 Market Street, Philadelphia, PA
THIS INSURANCE PROVIDES EXCESS SUPPLEMENTAL INSURANCE COVERAGE
This information summarizes the policy provisions, terms, exclusions and benefits. This policy will not pay 100% of all incurred medical expenses. Policy limits, terms and exclusions apply. Policy benefits are payable, subject to the limits specified below, for accidental bodily injury resulting from a covered accident (or covered illness if the optional In-Hospital Sickness Benefit Option is purchased). The company will pay the reasonable cost of covered eligible medical charges not to exceed the maximum benefits listed in the policy as summarized in this form. The maximum benefit payable for any one covered accident is $25,000.00. The maximum payable under the optional In-Hospital Sickness Benefit Option is $5,000.00 in the aggregate for all covered in-hospital expenses due to a covered hospital confinement. To be eligible for policy benefits, medical treatment by a licensed physician or dentist for a covered condition must be rendered within thirty (30) days from the original date of the covered injury or condition. The insurance company will pay for covered medical charges for treatment and care rendered within 52 weeks from the date of a covered accident or condition.
COVERAGE EFFECTIVE DATES: If application and payment for coverage is mailed to the insurance company or licensed insurance agent, coverage becomes effective at (1) 11:59 P.M. on the US Postal Service postmark date of the enrollment envelope or, (2) the date and time payment is received in the insurance company office or licensed agent’s office or (3) the first opening day of school scheduled classes in August 2017, whichever is the later date and time. If enrollment application and credit card payment is submitted via on-line enrollment, the coverage effective date is (1) the first opening day of school scheduled classes in August 2017 or, (2) at 12:01am on the day following the on-line enrollment application and credit card payment is submitted, whichever is the later date and time.
COVERAGE TERMINATION DATES: The $15.00 AT SCHOOL PLAN coverage terminates at 11:59pm on the last day of school classes of the 9-month 2017-2018 regular school term. The FULL TIME 24 HOUR Accident Plan coverage terminates at 11:59 P.M. on August 31, 2018. The In-Hospital Sickness Plan coverage terminates at 11:59 P.M. on August 31, 2018.
This policy provides EXCESS SUPPLEMENTAL INSURANCE COVERAGE: The insurance coverage provided under the policy shall be “EXCESS” to any other collectible insurance or plans, including but not limited to auto P.I.P. and auto med pay, self funded or pre-payment or pre-funded medical payments plans, employer, union or trade association sponsored insured or self-funded plans, HMOs or PPOs or coverage available from any other collectible source. subject to limits stated in the policy. Third party subrogation rights are reserved. Total payments by all insurance plans, including HMOs or PPOs, union or trade association self funded or prepayment medical plans or ERISA plans shall never exceed the total medical expenses incurred.
POLICY DEFINITIONS: “Covered Accident” means bodily injury of the insured that results directly and independently of all other causes from a covered accident occurring while the policy is in force. Self-inflicted injuries caused by prolonged over exertion, stress or strain, or disease process (unless the In-Hospital Sickness Option is purchased), or aggravation of an existing condition is expressly excluded from coverage under the accident policy. “Covered Charges” means reasonable charges which are not in excess of usual and customary charges; not in excess of the maximum benefit amount payable for services specified below; services and supplies which are not excluded from coverage; and services and supplies which are a medical necessity for treatment of the covered accident. “Pre-Existing Condition” means any physical condition for which the existence of symptoms would cause a normally prudent person to seek medical care or advice. Physical condition includes any complication or residual of a prior illness, condition or disease the person was advised or treated for in the six (6) months before the effective date of the Insured’s coverage under the policy. “Sickness” means an illness or disease for which symptoms first originate and for which medical treatment is rendered by a physician while this Endorsement is in force. All related conditions and recurrent symptoms of the same or a similar condition will be considered one sickness. “Hospital” means a licensed or properly accredited general hospital which is open at all times and operated primarily and continuously for the treatment of and surgery for sick and injured persons as inpatients under the supervision of one (1) or more legally qualified physicians available at all times with continuous, twenty-four (24) hour nursing services by Registered Nurses on duty or call. “Hospital” does not mean a facility that is primarily a clinic, nursing, rest or convalescent home, or an institution specializing in or primarily treating mental or nervous disorders, alcoholics or drug addicts. “FULL TIME 24-HOUR Accident Coverage” includes coverage during school hours and extends coverage to twenty-four (24) hours per day while a covered person is at home, away from school or on vacation. No benefits are payable for injuries sustained while practicing for or participating in interscholastic or other organized league sports competitions. Additional policy terms and provisions apply which are stated in the Master Blanket Accident Insurance Policy issued to the school district and on file for your review. “Effects of Other Coverage” means the insurance coverage provided under the policy shall be “EXCESS” to any other collectible insurance or plans, including but not limited to auto P.I.P. and auto insurance, self funded or prepayment medical payments plans, HMOs or PPOs, subject to limits stated in the policy. Third party subrogation rights are reserved. Total payments by all insurance plans, including HMOs or PPOs, union or trade association self funded or prepayment medical plans or ERISA plans shall never exceed the total medical expenses incurred.
EXCLUSIONS- WHAT THE STUDENT INSURANCE PLAN DOES NOT COVER: The student insurance plan does not cover any medical expenses due to the following activities or conditions: 1.) Participation in tackle football practices or competitions or participation in any other organized sports practices or competitions except those sports that are exclusively sanctioned, organized and scheduled by the school district during the regular school term; 2. Participation in classes, practices or competitions in boxing, self-defense, or martial arts, including but not limited to Karate, Aikido, Tae Kwon Do, Jujitsu, Kung Fu, kickboxing or weapons training. 3. Damage to other than whole, sound, vital and natural teeth or to existing dental bridges, crowns, restorations or braces or orthodontic procedure and services. 4. Treatment for injury or fracture of tooth caused either by decay, infection or the breakdown of a dental restoration. 3. Pathological fractures, stress fractures, boils, athlete’s foot, impetigo or similar skin infection, rashes, poisonous vegetation reactions, warts, blisters, calluses, cramps, muscle spasms, allergies or allergic reactions, ingrown nails, appendicitis, hernia of any kind, however caused; infections occurring other than as a result of a covered injury; detached retina; psychiatric care. 5. Any form of illness, sickness or disease including but not limited to the following: Perthes’ Disease, Osgood-Schlatter’s Disease, Osteomyelitis, Osteochondritis, Osteogenesis Imperfecta, Slipped Capital Femoral Epiphysis, Thrombophlebitis, Hysterical Reactions, or similar conditions (unless the In-Hospital Sickness Benefit Option is purchased). 6. Any form of fighting or brawling or criminal or felonious assault or the Insured being engaged in an illegal occupation. 7. Treatment rendered by a person related to the Insured person by blood or marriage. 8. Riding in or on, being struck by, being towed by, boarding or alighting from, or operating any motorized or engine-driven vehicle. Eligible medical expenses not collectible from other valid coverage will be payable up to $500.00 in the aggregate. 8. Intentionally self-inflicted injury. 9.War or any act of war (raids by air, land or sea shall be deemed act of war), civil disobedience, plots or insurrection. 10. Injuries sustained by the Insured for which benefits are payable under any Workers ’Compensation or Employer Liability Laws, or while engaging in activity for monetary gain from sources other than the Member. 11. Aviation in any form except while the Insured is riding as a passenger in a licensed airplane provided by an incorporated passenger carrier on a regularly scheduled passenger flight and route. 12. Riding in or on, being struck by, being towed by, boarding or alighting from, or operating any snowmobile, all-terrain vehicle, or two (2) or three (3) wheeled motor vehicle. 13. The use of or while under the influence of drugs unless administered as prescribed by a physician. 14. The existence or aggravation of physical or mental infirmity, condition or disease, whether infectious, congenital, secondary or acquired in origin. 15. Conditions or the aggravation of conditions that originated prior to the Insured’s insurance Effective Date. 16. Snow skiing, snow tubing, snowboarding, water skiing, wake boarding, surf boarding, hydro-sliding, jet skiing or using any "personal motorized watercraft", skateboarding. 17. Prescription drugs, injections, miscellaneous supplies and medications, except those administered while hospital-confined or when treated in the emergency room. 18. Any expense for which a specific policy benefit is not listed.
Additional Exclusions for the optional In-Hospital Sickness Benefit Plan: No benefits payable due to pregnancy, child birth, abortion; drug or alcohol intoxication, addiction or treatment expense; mental illness, emotional disorders, or psychiatric care; dental care for any cause including TMJ; any out-patient visit, treatment or service; any pre-existing condition or recurrence thereof; any expense due to accidental bodily injury.
HOW TO FILE A CLAIM: Contact the Lawrence E. Smith & Associates Agency claims department to request a claim form. Phone 800-325-1350; Fax 636-532-1737; Email firstname.lastname@example.org.
NOTE: The Student Accident and In-Hospital Sickness coverage plans are only available to students enrolled and attending classes in grades Pre-Kindergarten through grade 12 in the school district. This coverage option is not available to high school graduates, college students, children that attend other school districts or adults. If an insurance enrollment application or a claim is received by the insurance company or insurance agent for a person that is not eligible to be enrolled in the student insurance plans, coverage for the ineligible person will not be effective and the ineligible person’s application and full insurance premium payment will be returned to the ineligible person. This is a summary of the insurance plan benefits. All claims will be paid in accordance with the master policy provisions.