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2004_278_1.qxp2004 - 2005
STUDENT INJURY AND SICKNESS
Designed Especially for
the Students of
We know that your privacy is important to you and we strive to protect the confidentiality of your nonpublic personalinformation. We do not disclose any nonpublic personal information about our customers or former customers toanyone, except as permitted or required by law. We believe we maintain appropriate physical, electronic andprocedural safeguards to ensure the security of your nonpublic personal information. You may obtain a copy of our Eligibility
All registered full-time students are required to purchase this insurance Plan unless proof of comparablecoverage is furnished.
All registered part-time students taking at least 6 credit hours and all registered Keller Graduate School studentstaking credit hours are eligible to enroll in the insurance Plan on a voluntary basis. All part-time students takingless than 6 credit hours are not eligible for this insurance coverage.
Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased.
The MEGA Life and Health Insurance Company maintains its right to investigate student status and attendancerecords to verify that the Policy Eligibility requirements have been met. If the Company discovers the Eligibilityrequirements have not been met, its only obligation is to refund premium.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the spouse andunmarried children under 19 years of age, or 23 years if a full-time student at an accredited institution of higherlearning who are not self-supporting. Dependent Eligibility expires concurrently with that of the Insured student.
The student has 31 calendar days from date of marriage, birth of child, divorce, to add eligible Dependents.
Effective and Termination Dates
The Master Policy on file at the school becomes effective at 12:01 a.m., November 1, 2004. Coverage becomeseffective on the first day of the period for which premium is paid or the date the enrollment form and fullpremium are received by the Company (or its authorized representative), whichever is later. The Master Policyterminates at 12:01 a.m., November 1, 2005. Coverage terminates on that date or at the end of the periodthrough which premium is paid, whichever is earlier. Dependent coverage will not be effective prior to that ofthe Insured student or extend beyond that of the Insured student.
If paying premiums by Semester, coverage is as follows: Fall November 01, 2004 to March 07, 2005Fall Semester AOctober 25, 2004 to March 07, 2005Fall Semester BJanuary 03, 2005 to March 07, 2005Spring .March 07, 2005 to July 11, 2005Spring Semester AFebruary 28, 2005 to July 11, 2005Spring Semester BApril 25, 2005 to July 11, 2005SummerJuly 04, 2005 to November 01, 2005Summer Semester AJuly 04, 2005 to November 01, 2005Summer Semester BAugust 29, 2005 to November 01, 2005 You must meet the Eligibility requirements each time you pay a premium to continue insurance coverage. Toavoid a lapse in coverage, your premium must be received within 14 days after the coverage expiration date. Itis the student’s responsibility to make timely renewal payments to avoid a lapse in coverage.
Refunds of premiums are allowed only upon entry into the armed forces.
The Policy is a Non-Renewable One Year Term Policy. It is the Insured’s responsibility to obtain coverage thefollowing year in order to maintain continuity of coverage. Alternative coverage
If you do not meet the eligibility requirements of the Plan, please call 1-800-406-2338 for information onalternative coverage. Extension of Benefits After Termination
The coverage provided under the Policy ceases on the Termination Date. However, if an Insured is HospitalConfined on the Termination Date from a covered Injury or Sickness for which benefits were paid before theTermination Date, Covered Medical Expenses for such Injury or Sickness will continue to be paid as long as thecondition continues but not to exceed 90 days after the Termination Date.
The total payments made in respect of the Insured for such condition both before and after the Termination Datewill never exceed the Maximum Benefit. After this “Extension of Benefits” provision has been exhausted, allbenefits cease to exist, and under no circumstances will further payments be made.
Choice of Plan
Each eligible student has a choice of one of the benefit plans. Plan II has higher benefits than Plan I and it has
a higher premium. Make your selection carefully, you cannot upgrade coverage after the initial purchase
of the Plan for the Policy year. Please be aware that if you choose to change policies to upgrade coverage in
any subsequent Policy year, a new Pre-existing Condition exclusion and waiting period will apply.
Value Check should be notified of all Hospital Confinements prior to admission.
1. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS:
Physician or Hospital should telephone 1-877-295-0720 at least five working days prior to the plannedadmission.
2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient’s representative,
Physician or Hospital should telephone 1-877-295-0720 within two working days of the admission or as soonas possible after the patient becomes lucid and able to communicate to provide the notification of anyadmission due to Medical Emergency.
Value Check is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m., C.S.T., Monday throughFriday. 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.
There are certain maternity tests that may be routinely performed by your Physician that may not be coveredunder the Policy. Please call the Company at 1-800-767-0700 for additional information.
Benefits for Mammography
Benefits will be paid the same as any other Sickness for screening by Low-dose Mammography for the presenceof occult breast cancer according to the following guidelines:1. A baseline mammogram for women thirty-five to thirty-nine years of age.
2. A mammogram every one to two years, even if no symptoms are present, for women forty to forty-nine years 3. An annual mammogram for women fifty years of age or older.
"Low-dose mammography" means the x-ray examination of the breast using equipment dedicated specificallyfor mammography, including the x-ray tube, filter, compression device, and image receptor, with radiationexposure delivery of less than one rad per breast for 2 views of an average size breast.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any other provisions of thepolicy.
Benefits are provided as mandated by the State of Illinois such as: Benefits for Colorectal Cancer Test, Benefitsfor Initial Prosthetic Device and Reconstructive Surgery, Benefits for Cervical Cancer Screening Test, Benefitsfor Prostate Cancer Screening, and Benefits for Diabetes. A detail of these benefits may be found in the MasterPolicy on file at the school in the Student Services Office.
Special Provider Arrangements
Beech Street Network of Hospitals has agreed to accept special reduced reimbursement rates for treatmentrendered to students. Eligible Hospital services provided by Beech Street Network of Hospitals will be paid upto the Schedule of Medical Expense Benefits limits after the provider discount.
You will be responsible for all out of pocket expenses in excess of the insurance policy benefits based on thelimitations contained in the Schedule of Medical Expense Benefits.
Intercollegiate Sports Plan I
Maximum Benefit $10,000
(For Each Injury)
Plan II Maximum Benefit $25,000
(For Each Injury)
Insured student athletes who are members of and are participating in intercollegiate basketball and softballsponsored by the Policyholder are covered for sports Injury as for any other Injury.
Benefits will be paid under the Schedule of Benefits for intercollegiate sports Injury up to $10,000 for eachInjury under Plan I and up to $25,000 for each Injury under Plan II.
No benefits will be paid for: 1) Infections, except pyogenic infections caused wholly by a covered Injury; 2)Cysts, blisters, or boils; 3) Overexertion; heat exhaustion; fainting; 4) Hernia, regardless of how caused; or 5)Artificial aids such as crutches, braces, appliances, and artificial limbs.
No benefits are payable for any expense incurred for Injury or Sickness which has been paid or is payable byother valid and collectible insurance.
This excess provision will not be applied to the first $100 of medical expenses incurred.
Covered Medical Expenses excludes amounts not covered by the primary carrier due to penalties imposed on theInsured for failing to comply with policy provisions or requirements.
Important: The Excess Provision has no practical application if you do not have other medical insurance or ifyour other insurance does not cover the loss.
All Insured Persons who have been continuously insured under the school’s regular student Policy for at least 6consecutive months and who no longer meet the Eligibility requirements under the Policy are eligible to continuetheir coverage for a period of not more than nine months under the school’s policy in effect at the time of suchcontinuation. If an Insured Person is still eligible for continuation at the beginning of the next Policy Year, theInsured must purchase coverage under the new policy as chosen by the school. Coverage under the new policyis subject to the rates and benefits selected by the school for that policy year.
Application must be made and premium must be paid directly to Student Insurance and be received within 14days after the expiration date of your student coverage. For further information on the Continuation privilege,please contact Student Insurance.
Insured Students have access to nurse advice and health information 24 hours a day, 7 days a week by dialing 1- 800-883-2951. The NurseLine is staffed by Registered Nurses who can help students determine if they need to seek medical care, understand their medications or medical procedures, or learn ways to stay healthy.
Assist America: Global Emergency
Through participation in the DeVry University insurance plan, each Insured is eligible for global emergency medical assistance services when traveling 100 miles or more from his/her permanent home or campus address or abroad.
Services are accessible 24 hours a day, 365 days a year and are provided by Assist America, Inc. Services include evacuation, repatriation and return of mortal remains. Once the participant is ready to be released from the hospital, Assist America will arrange and pay to transport the participant to his/her residence or rehabilitation facility, with medical supervision, if necessary. More detailed information regarding this service can be found at Assist America is not travel or medical insurance, but a service provider for emergency medical assistance services.
All medical cost incurred should be submitted to your health plan and are subject to the policy limits of your health Definitions
INJURY means bodily injury which is: 1) directly caused by specific accidental contact with another body or
object; 2) unrelated to any pathological, functional, or structural disorder; 3) a source of loss; 4) treated by a
Physician within 30 days after the date of accident; and 5) sustained while the Insured Person is covered under
this policy. All injuries sustained in one accident, including all related conditions and recurrent symptoms of
these injuries will be considered one injury. 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.
PRE-EXISTING CONDITION means: 1) the existence of symptoms which would cause an ordinarily prudent
person to seek diagnosis, care or treatment within the 12 months immediately prior to the Insured's Effective
Date under the policy; or, 2) any condition which originates, is diagnosed, treated or recommended for treatment
within the 12 months immediately prior to the Insured's Effective Date under the policy.
SICKNESS means sickness or disease of the Insured Person which causes loss, and originates while the Insured
Person is covered under this policy. 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.
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 of the Policyholder. 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 or resulting from; or b) treatment, services or suppliesfor, at, or related to: 1. Acne; allergy, including allergy testing;2. Addiction, such as nicotine addiction;3. Learning disabilities;4. Biofeedback;5. Durable Medical Equipment;6. Circumcision;7. Congenital conditions, except as specifically provided for Newborn or adopted Infants;8. 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; removal of warts, non-malignant moles andlesions; 9. Dental treatment, except for accidental Injury to Sound, Natural Teeth;10. Elective Surgery or Elective Treatment;11. Elective abortion;12. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects and problems; except when due to adisease process; 13. Foot care including: care of corns, bunions (except capsular or bone surgery), calluses;14. 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 can impair normal hearing, apart from thedisease process; 15. Hirsutism; alopecia;16. Immunizations, preventive medicines or vaccines, except where required for treatment of a covered Injury;17. Injury caused by or resulting from addiction to alcohol, intoxicants, hallucinogenics, illegal drugs or any drugs or medicines that are not taken in the recommended dosage or for the purpose prescribed by the InsuredPerson's Physician; Intoxication is defined and determined by the laws of the state where the loss or cause ofthe loss was incurred; 18. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 19. Injury sustained while (a) participating in any interscholastic, or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c) while participating in anypractice or conditioning program for such sport, contest or competition; 20. Organ transplants, only those considered experimental are excluded;21. Outpatient Physiotherapy; except for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2) within the 30 days immediately following theattending Physician's release for rehabilitation; 22. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting;23. Pre-existing Conditions, except for individuals who have been continuously insured under the school's student insurance policy for at least 12 consecutive months; 24. Prescription Drugs, services or supplies as follows: a. Therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use; 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;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 EXCLUSIONS AND LIMITATIONS (Continued)
Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; h. Growth hormones, except when a Medical Necessity; or i. Refills in excess of the number specified or dispensed after one (1) year of date of the prescription.
25. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversal of sterilization procedures; 26. 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; 27. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specifically provided in the policy; 28. Services provided normally without charge by the Health Service of the Policyholder; or services covered or 29. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; nasal and sinus surgery; 30. 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 regularly scheduled flight of a commercial airline 32. Supplies, except as specifically provided in the policy; 33. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; 34. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such 35. 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; 36. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of Claim Procedure
In the event of Injury or Sickness, students should: 1) Report to their Physician or Hospital.
2) Mail to the address below all medical and hospital bills along with the patient’s name and Insured student’s name, address, social security number and name of the school under which the student is insured. A Companyclaim form is not required for filing a claim. 3) File claim within 60 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 90 days of service. Bills submitted after one year will not be considered for payment except in theabsence of legal capacity.
The Plan is Underwritten by:
The MEGA Life and Health
Submit all Claims or Inquiries to:
Sales and Marketing
805 Executive Center Drive West-Suite 220 ONLINE SERVICES:
Please visit our WAdobeAcrobat), Coverage Receipts, ID Cards, Claims Status and other services.
Please keep this Brochure as a general summary of the insurance. The Master Policy on file at the StudentServices Office contains all of the provisions, limitations, exclusions and qualifications of your insurancebenefits, some of which may not be included in this Brochure. The Master Policy is the contract and will governand control the payment of benefits.
2004-278-1 Plan I
2004-278-2 Plan II
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