SABA University School of Medicine, Accident and Sickness Insurance (“Clinical Rotation” Students and Dependents)

Underwritten By: ACE American Insurance Company (Herein referred to as “We”, “Our”, or “Us”)

Eligibility

All domestic and international students who are studying in the United States and participating in the Clinical Medicine portion of the Medical Degree Program are eligible to enroll in the Student Accident and Sickness Insurance Plan.  Eligibility is extended to students while taking sabbatical to study for the United States Medical Licensing Exam.  Students enrolled in the Student Accident and Sickness Insurance Plan may also enroll their dependent(s) as defined. “Dependent” means: (a) the Insured Student’s spouse residing with the Insured Student; or (b) the Insured Student’s unmarried children under the age of nineteen years; or (c) a child born to an Insured Student while this Plan is in force will be covered by this Plan. Coverage for such newborn children will consist of coverage for accident or sickness, including necessary care or treatment of congenital defects, birth abnormalities, or premature birth. Such coverage will start from the moment of birth, if the Insured Student is already insured for dependent coverage when the child is born.  If the Insured Student does not have dependent coverage when the child is born, We cover the newborn child, for dependent benefits, for the first 31 days from the moment of birth.  An adopted child will be covered on the same basis as a newborn child from the date of placement by a licensed placement agency, in the Insured Student’s home, for purposes of adoption. A foster child will be covered from the date of the filing of a petition to adopt, if the child has been residing in the Insured Student’s home as a foster child from when the Insured Student has received foster care payments.  To continue the child’s dependent benefits past the first 31 days, the Insured Student must complete and return the Dependent Enrollment Form with payment within 31 days of the child’s birth.

Period of Coverage

Insurance becomes effective at 12:01 A.M. at the University’s address on the latest of: 1) the effective date of the Policy, September 1, 2005; or 2) the date the person becomes eligible; or 3) the date the enrollment form and full premium are received by the Plan Administrator or Us.  Insurance will terminate at 12:01 A.M. Standard Time on the earliest of the following dates: 1) September 1, 2006; or 2) the last day of the period through which the premium is paid; or 3) the date the eligibility requirements are not met; or 4) the date the Covered Person enters full-time active duty service in any Armed Forces.  A refund of premium will be made when We receive proof of active duty.

Definitions

You, Your or Yours means the Insured Student.  Covered Person means any Insured Student and Dependent who enrolls for coverage and for whom the required premium is paid.  Injury means accidental bodily harm sustained by a Covered Person that results directly and independently from all other causes from a Covered Accident.  The Injury must be caused solely through violent and accidental means.  All injuries sustained by one person in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered a single Injury.  Sickness means an illness, disease or condition of the Covered Person that causes a loss for which a Covered Person incurs medical expenses while covered under the Policy.  All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness. Doctor means a licensed health care provider acting within the scope of his or her license and rendering care or treatment to a Covered Person that is appropriate for the conditions and locality.  It will not include a Covered Person or a member of the Covered Person’s immediate family member or household.  Covered Expenses means expenses actually incurred by or on behalf of a Covered Person for treatment, services and supplies covered by the Policy.  Coverage under the Policy must remain continuously in force from the date of the Accident or Sickness until the date treatment, services or supplies are received for them to be a Covered Expense.  A Covered Expense is deemed to be incurred on the date such treatment, service or supply, that gave rise to the expense or the charge, was rendered or obtained.  Medical Emergency means a condition caused by an Injury or Sickness that manifests itself by symptoms of sufficient severity that a prudent lay person possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of the person in serious jeopardy.  Usual and Customary Charge(s) means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided.  Medically Necessary means a treatment, service or supply that is: 1) required to treat an Injury or Sickness; 2) prescribed or ordered by a Doctor or furnished by a Hospital; 3) performed in the least costly setting required by the Covered Person’s condition; and 4) consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered. A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may at Our discretion, consider the cost of the alternative to be the Covered Expense.

Medical Expense Benefits

We will pay, after a $100.00 deductible per Injury or Sickness, 80% of the Usual and Customary Charge incurred for the first $20,000; then 100% of the Usual and Customary Charge incurred up to an Aggregate Maximum of $500,000 per covered Injury or Sickness.

Hospital Expense Benefit:  We will pay 80% of the Usual and Customary Charge incurred up to a maximum of $1,800 per day. The Hospital Expense Benefit includes coverage for Hospital Room & Board and Hospital Miscellaneous Expense.

Hospital Room and Board Expense:  If a Covered Person requires confinement in a hospital, We will pay 80% of the Usual and Customary Charge incurred up to the semi-private room rate or Intensive Care Unit rate subject to the Hospital Expense Benefit Maximum.

Hospital Miscellaneous Expense:  If a Covered Person incurs Expenses during a hospital confinement, or day surgery on an outpatient basis for: anesthesia, operating room, laboratory tests, x-rays, oxygen tent, drugs, medicines, dressings, and other necessary non-room and board expenses, We will pay 80% of the Usual and Customary Charge incurred subject to the Hospital Expense Benefit Maximum.

Surgical Expense (Inpatient or Outpatient):  We will pay the Usual and Customary Charge incurred, for surgery performed by a licensed Doctor (In or Out of the Hospital). Benefits will be paid in accordance with the Medical Data Research Schedule for Usual and Customary Charge.

Anesthesiologist Expense:  If a Covered Person requires an anesthesiologist for a surgical operation, We will pay the Usual and Customary Charge incurred for such expense.

Assistant Surgeon Expense:  If a Covered Person requires an assistant surgeon for a surgical operation, We will pay the Usual and Customary Charge incurred for such expense.

In-Hospital Doctor’s Fees Expense:  If a Covered Person requires the services of a Doctor, other than a surgeon, while confined to a hospital, We will pay the Usual and Customary Charge incurred, limited to one visit per day.

Outpatient Doctor Visit Expense:  If a Covered Person requires the services of a Doctor, We will pay the Usual and Customary Charge incurred, limited to one visit per day.

Hospital Outpatient Department Expense:  If a Covered Person requires services while not hospital confined for the use of the Hospital Outpatient Department or other outpatient facility, We will pay the Usual and Customary Charge incurred for such expense.

Emergency Room Expense:  If a Covered Person requires the use of a hospital emergency room as a result of a Medical Emergency, We will pay the Usual and Customary Charge incurred for such expense.

Diagnostic X-ray and Laboratory Expense:  If a Covered Person is prescribed by an attending Doctor for diagnostic x-ray and laboratory services on an outpatient basis, We will pay the Usual and Customary Charge incurred for such expense.

Pre-Admission Test Expense:  If a Covered Person requires Pre-Admission Testing, We will pay the Usual and Customary Charge incurred for the reimbursement of charges made by a hospital for use of its outpatient facilities for tests ordered by a Doctor.  The tests must be performed as planned preliminary to the Insured Person’s admission as inpatient for surgery in that same hospital. However: (a) the test must be necessary for, and consistent with, the diagnosis and treatment of the condition for which surgery is to be performed; (b) reservations for a hospital bed and for an operating room must be made prior to the date the test are done; (c) the surgery actually takes place within seven days of pre-surgical tests; and (d) the Covered Person is physically present at the hospital for the tests.

Outpatient Prescription Drug Expense:  If a Covered Person requires a prescription drug prescribed by a Doctor, We will pay the Usual and Customary Charge incurred for such expense.

Ambulance Expense:  If a Covered Person requires the use of a community or hospital ambulance for a Medical Emergency, We will pay 100% of the Usual and Customary Charge incurred up to a maximum of $250.00 per Injury or Sickness.

Voluntary Abortion Expense:  If as a result of pregnancy having its inception during the term insured, a Covered Person has a voluntary abortion, We will pay 100% of the Usual and Customary Charge incurred up to a maximum of $350.00. Expenses for the voluntary abortion must be incurred while the Plan is in force as to the Covered Person.

Physiotherapy/Chiropractic Care Outpatient Expense:  If a Covered Person incurs expenses for Medically Necessary physiotherapy or chiropractic outpatient treatments, We will pay the Usual and Customary Charge incurred for such treatments. Physiotherapy/Chiropractic Care means heat treatment or diathermy, Ultrasonic, microtherm, manipulation, adjustment, massage therapy and acupuncture.  Services must be prescribed by a licensed Doctor and must include a prescription for a stated number of treatments. The referring Doctor must issue a new prescription following medical evaluation of the Covered Person’s condition, for any additional treatment required for the condition.

Mental and Nervous Benefits
Inpatient Expense:   If a Covered Person requires treatment for mental and nervous disorders while hospital confined, We will pay the Usual and Customary Charge incurred for any such confinement on the same basis as any other Sickness, but payment will not be made for more than 60 days per policy year.
Outpatient Expense:   If a Covered Person is not hospital confined, We will pay 80% of the Usual and Customary Charge incurred up to a maximum of $500.00 per policy year.

Alcohol and Substance Abuse Benefits
Inpatient Expense:    If due to alcoholism, alcohol abuse, substance abuse, or substance dependency, a Covered Person requires treatment during a confinement in a hospital, Detoxification Facility, or residential alcohol and substance treatment program for persons remanded to such programs for drunk driving, We will pay the Usual and Customary Charge for any such confinement on the same basis as any other Sickness, but payment will not be made for more than 30 days in any one calendar year. 
Outpatient Expense:  If due to alcoholism, alcohol abuse, or substance dependency, a Covered Person requires outpatient treatment services in a hospital or Detoxification Facility, We will pay 80% of the Usual and Customary Charge for outpatient services, up to a maximum of $500.00 per policy year.

Mammography Examination Expense:   If a Covered Person requires a mammography exam, We will pay for the following: (a) a baseline mammogram for women between the ages of thirty-five and forty years of age and older; or (b) a mammogram on an annual basis for women forty years of age and older.

Cytologic Screening Expense:   If a Covered Person eighteen years of age or older requires a cytologic screening (pap smear), We will pay a cytologic screening once a year, or more frequently if recommended by a Doctor. Such benefits will include the examination, laboratory fee, and the Doctor’s interpretation of the laboratory results.

Maternity Expense:   If a Covered Person or spouse is pregnant, We will pay for any Expense incurred which are medically necessary including expenses for prenatal care, childbirth and post partum care (including well baby care on the same basis as any other Sickness. (Elective abortion and elective cesarean section are not included as covered expenses.)  Expenses for childbirth include hospital inpatient care of not less than 48 hours following a vaginal delivery or not less than 96 hours following a cesarean section, unless the attending physician, in consultation with the mother makes a decision for an earlier discharge from the hospital. Covered Expenses will also include expenses for post-delivery care such as but not limited to: home visits, parent education, assistance and training in breast or bottle feeding and the performance of any necessary and appropriate clinical tests. However, the first home visit must be conducted by a registered nurse, certified nurse midwife or physician and any future home visits determined to be necessary must be provided by a licensed health care provider.

Preventive and Primary Care Expense for Children:   We will pay 80% of the Expense incurred for preventive and primary care expenses actually incurred.  These are for services rendered to a dependent child of a Covered Person from the date of birth through the attainment of six years of age. These services are limited to the following: physical examination, history, measurements, sensory screening, neuropsychiatric evaluation and development screening, and assessment at the following intervals: six times during the child’s first year after birth, three times during the next year, annual until age six.  Such services will also include hereditary and metabolic screening at birth, appropriate immunizations, and tuberculin tests, hematocrit, hemoglobin or other appropriate blood tests, and urinalysis as recommended by the Doctor.

Hospice Care Treatment Expense:   We pay for charges made by a licensed hospice for the Covered Expenses of a Covered Person with a life expectancy of six months or less.  Services must be authorized by a duly licensed physician.

Early Intervention Services Expense:   We will pay 80% of the Expense actually incurred up to a maximum of $3,200 per policy year and $9,600 over the total enrollment for Early Intervention Services. These services include occupational, physical, speech therapy; nursing care and psychological counseling. Expenses are payable for a dependent child of an Insured Person from birth until their third birthday.

High Cost Outpatient Procedures Expense:   If a Covered Person incurs expenses for specific outpatient procedures costing over $200, We will pay 80% of the Usual and Customary Charges incurred up to $2,000 per covered Injury or Sickness.  Specific outpatient procedures include, but are not limited to: CAT scan, magnetic resonance imaging and laser treatments.  This benefit is payable in addition to any other benefit payable under this insurance program.

Off Label Use of Prescription Drugs Expense:   We will pay benefits for expenses incurred for off label use of prescription drugs that have not been approved by the Federal Drug Administration for the treatment of cancer and HIV/AIDS.

Cardiac Rehabilitation Expense:   If a Covered Person requires Cardiac Rehabilitation treatment in connection with documented cardiovascular disease. We will pay for such treatment on the same basis as any other Sickness.  Such treatment shall include, but is not limited to, outpatient treatment which is to be initiated within 26 weeks after the diagnosis of such disease.

Infertility Expense:   If a Covered Person incurs medically necessary expenses for diagnosis and treatment of Infertility, We will pay benefits on the same basis as any other Sickness.  Covered Expenses include expense incurred for the following non-experimental infertility procedures: (1) Artificial Insemination; (2) In Vitro Fertilization and Embryo Placement; (3) Sperm, egg and/or inseminated egg procurement, processing and banking to the extent such costs are not covered by the donor’s insurer, if any; (4) Gamete Intra Fallopian Transfer; (5) Intracytoplasmic Sperm Injection for the treatment of male factor infertility; and (6) Zygote Intrafallopian Transfer.  The term “Infertility” means the condition of a presumably healthy individual who is unable to conceive or produce conception during a period of one year.

Home Health Care Expense:   When, by reason of Injury or Sickness, a Covered Person incurs Expenses for covered home health care services. We will pay, after a $50.00 deductible, on the same basis as any other Injury or Sickness for the Expenses incurred up to a maximum of 40 visits within 12 months from the date of the first home health care visit. Four hours of home health care is considered one home care visit.

Non-prescription Enteral Formulas Expense:   We will pay up to $2,500.00 per policy year for benefits for non-prescription enteral formulas which are medically necessary for the treatment of mal absorption caused by Crohn’s Disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility, chronic intestinal pseudo-obstruction, and inherited disease of amino acids and organic acids.

Bone Marrow Transplant for Treatment of Breast Cancer Expense:   If a Covered Person has metastatic breast cancer, We will pay 80% of the Covered Expenses up to the Aggregate Maximum for the expense of a bone marrow transplant for the treatment of breast cancer.

Glucose Monitoring for Diabetic Treatment Expense:   If a Covered Person has insulin dependent diabetes, We will pay 80% of the Covered Expenses for blood glucose monitoring strips for home use for which a Doctor has written an order and are medically necessary for the treatment of insulin dependent diabetes.

Services Performed By Certified Registered Nurse Anesthetists and Nurse Practitioners Expense:   We pay for services by Nurse Practitioners and Certified Registered Nurse Anesthetists (CRNA) if the service performed is within the scope of the nurse practitioner’s authority to practice or the CRNA’s license and if the Plan currently provides benefits for identical services rendered by a health care provider licensed in Massachusetts.

Special Medical Formulas Expense:   Coverage will be provided for special medical formulas which are approved by the Commissioner of the Department of Health, prescribed by a Doctor, and are Medically Necessary expenses for treatment of phenylketronia, tyrosinemia, homo-cystinuria, maple syrup urine disease, propionic acidemia, or metylmolonic acidemia in infants and children or are Medically Necessary to protect the unborn child of pregnant women with phenylktonuria.

Reconstructive Breast Surgery Expense:   If a Covered Person incurs an expense for reconstructive surgery following a mastectomy, We will pay the Usual and Customary Charges incurred for such expense.

Emergency Medical Evacuation

We will pay benefits for covered expenses incurred up to the maximum of $250,000 for the necessary Emergency Medical Evacuation of you or a covered Dependent. Emergency Medical Evacuation means: a) the Covered Person’s medical condition warrants immediate transportation from the place where the Covered Person is injured or ill to the nearest hospital where appropriate medical treatment can be obtained; or b) after being treated at a local hospital, the Insured Person’s medical condition warrants transportation to the Home Country to obtain further medical treatment or to recover. Covered Expenses are expenses, up to the maximum amount payable, for transportation, medical services and medical supplies necessarily incurred in connection with Emergency Medical Evacuation of the Insured Person. All transportation arrangements made for evacuating the Insured Person must be by the most direct and economical conveyance, and approved in advance by Us. Expenses for special transportation must be recommended by the attending physician or required by the standard regulations of the conveyance transporting the Insured Person. Special transportation includes, but is not limited to, air ambulance, land ambulance and private motor vehicle. Expenses for medical supplies and services must be recommended by the attending Doctor. Transportation means land, water or air conveyance to transport the Insured Person during an Emergency Medical Evacuation. All arrangements must be made by the Assistance Provider and approved by Us in order for expenses to be considered eligible.

Repatriation of Remains 

We will pay benefits for the reasonable covered expenses, up to a maximum of $50,000, to return a Covered Person’s body home to the Home Country if he or she dies while covered by this Plan. Covered expenses include, but are not limited to, expenses for embalming, cremation, coffins and transportation. All arrangements must be made by the Assistance Provider and approved by Us in order for expenses to be considered eligible.

Full Excess Coverage

We pay Covered Expenses: 1) after the Covered Person satisfies any Deductible; and 2) only when they are in excess of amounts paid by any other Health Care Plan.

We pay benefits without regard to any Coordination of Benefits provisions in any other Health Care Plan shall be excess of all other valid and collectible insurance.