2011-201293-92-benefit summary flyer-compliance-v6_summary-temp-

Student Injury and Sickness
Insurance Plan for
International Community Service -
Vantage Plan

International Community Service is pleased to offer an Injury and Sickness Insurance Plan This plan is underwritten byunderwritten by UnitedHealthcare Insurance Company. All regular, full time and part time eligible students, scholars or other persons with a current passport who: 1) are engaged in international educational activities; and 2) are temporarily located outside his/her home country as a non resident alien; and 3) have not obtained permanent residency status areeligible to enroll in this Plan on a voluntary basis. Those enrolled in an Optional Practical Training program (with a F-1 or J-1 visa) who were previously enrolled in this Plan are eligible.
Eligible Dependents of insured student may enroll concurrently on a voluntary basis. The Named Insured must actively attend classes for at least the first 31 days after the date for which coverage is purchased, with the exception of those with a J Visa or those in an Optional Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:

Up to $250,000 for each Injury or Sickness Maximum Benefit for Covered Medical Covered Medical Expenses for Preferred Provider are payable at 80% of Preferred Allowances and Out of Network benefits are payable at 70% of Usual and Customarycharges (all benefits are subject to satisfaction of the deductible, specific benefit limitations, maximum and copays as described in the policy).
$100 Deductible for each Injury or Sickness. The maximum Deductible for any oneInsured will not exceed $500 Per Policy Year.
The Deductible will be waived if treatment is received at a Recognized Student HealthCenter. The Preferred Provider for this plan is UnitedHealthcare Options PPO.
Prescription Drug Benefits: 80% of Usual and Customary Charges ($2,000 maximum per Coverage available for eligible dependents.
Scholastic Emergency Services – International Students are covered worldwide except intheir home country.
MyAccount, available through www.firststudent.com, allows insured students access24/7 to check their claim status, search for network providers, print ID cards, enteraccident details, view EOBs and enter additional insurance information online.
Included with every policy, the UnitedHealth Allies® discount program provides 5% to 50% savings on dental and vision services, fitness clothing and equipment, andtextbooks from McGraw-Hill Professional. The UnitedHealth Allies program is not insurance and is offered by UnitedHealth Allies, a UnitedHealth Group company.
UnitedHealthcare StudentResources
School Benefit Summary
2011-201293-92-Benefit Summary Flyer
PRE-EXISTING CONDITION means any condition which is Adopted Child Effective date under this policy.
diagnosed, treated or recommended for treatment within the 6 20. Prescription Drugs, services or supplies as follows: months immediately prior to the Insured's Effective Date under the a) Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use except as specifically No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or b) Birth control and/or contraceptives, oral or other, whether medication or device, regardless of intended use; c) Immunization agents, biological sera, blood or blood products 2. Addiction, such as: nicotine addiction and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending, d) Drugs labeled, “Caution – limited by federal law to shopping, working and religious; codependency; investigational use” or experimental drugs; except as e) Products used for unapproved cosmetic indications; 5. Congenital conditions, except as specifically provided for f) Drugs used to treat or cure baldness; anabolic steroids used 6. Cosmetic procedures, except cosmetic surgery required to g) Anorectics - drugs used for the purpose of weight control; correct an Injury for which benefits are otherwise payable under h) Fertility agents or sexual enhancement drugs, such as this policy or for newborn or adopted children; removal of warts, Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or 7. Custodial care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or j) Refills in excess of the number specified or dispensed after places mainly for domiciliary or custodial care; extended care in one (1) year of date of the prescription; treatment or substance abuse facilities for domiciliary orcustodial care; 21. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including 8. Dental treatment, except for accidental Injury to Teeth; any services or supplies rendered for the purpose or with the 9. Elective Surgery or Elective Treatment; intent of inducing conception; premarital examinations; 10. Eye examinations, eye refractions, eyeglasses, contact lenses, impotence, organic or otherwise; tubal ligation; vasectomy; prescriptions or fitting of eyeglasses or contact lenses, vision sexual reassignment surgery; reversal of sterilization correction surgery, or other treatment for visual defects and problems; except when due to a disease process; 22. Research or examinations relating to research studies, or any 11. Foot care including: care of corns, bunions (except capsular or treatment for which the patient or the patient’s representative must sign an informed consent document identifying the 12. Immunizations, except as specifically provided in the policy; treatment in which the patient is to participate as a research preventive medicines or vaccines, except where required for treatment of a covered Injury or as specifically provided in the 23. Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48 hours for vaginal delivery or 13. Injury or Sickness for which benefits are paid under any Workers' Compensation or Occupational Disease Law or Act, or similar 24. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence 14. Injury sustained by reason of a motor vehicle accident to the of Injury or Sickness; except as specifically provided in the policy; extent that benefits are paid or payable by any other valid and 25. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the 15. Injury sustained while (a) participating in any interscholastic, club, intercollegiate, or professional sport, contest or 26. Deviated nasal septum, including submucous resection and/or competition; (b) traveling to or from such sport, contest or other surgical correction thereof; nasal and sinus surgery, except competition as a participant; or (c) while participating in any for treatment of chronic purulent sinusitis; practice or conditioning program for such sport, contest or 27. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of aircraft, except 16. Organ transplants, including organ donation; while riding as a passenger on a regularly scheduled flight of a 17. Outpatient Physiotherapy; except for a condition that required surgery or Hospital Confinement: 1) within the 30 days 28. Suicide or attempted suicide while sane or insane (including immediately preceding such Physiotherapy; or 2) within the 30 drug overdose); or intentionally self-inflicted Injury; days immediately following the attending Physician's release for 29. Supplies, except as specifically provided in the policy; 30. Surgical breast reduction, breast augmentation, breast implants 18. Participation in a riot or civil disorder; commission of or attempt or breast prosthetic devices, or gynecomastia; except as 31. Treatment in a Government hospital, unless there is a legal 19. Pre-existing Conditions, for a period of 6 months, except for obligation for the Insured Person to pay for such treatment; individuals who have been continuously insured under theInternational Community Service insurance policy for at least 6 32. War or any act of war, declared or undeclared; or while in the consecutive months; Credit will be given for the time the Insured armed forces of any country (a pro-rata premium will be was covered under previous Creditable Coverage if the refunded upon request for such period not covered); and Creditable Coverage was continuous to a date not more than 33. Weight management, weight reduction, nutrition programs, sixty-three (63) prior to the Insured’s Effective Date under this treatment for obesity, surgery for removal of excess skin or fat, Policy; or 2) a Newborn Infant or Adopted Child who has been and treatment of eating disorders such as bulimia and anorexia.
continuously insured under previous Creditable Coverage since Exception: benefits will be provided for the treatment of birth or adoption if the Creditable Coverage was continuous to a dehydration and electrolyte imbalance associated with eating date not more than 63 days prior to the Insured Newborn or

Source: http://www.transpoints.com/icsweb/icsdocs/2011UH12/introv.pdf

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