Table of Contents
Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8UnitedHealthcare Network Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Accidental Death & Dismemberment Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Benefits for Severe Mental Illnesses and Serious Emotional Disturbances . . . . .11 Additional Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . .15Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality ofyour nonpublic personal information. We do not disclose any nonpublic personal informationabout our customers or former customers to anyone, except as permitted or required by law.
We believe we maintain appropriate physical, electronic and procedural safeguards toensure the security of your nonpublic personal information. You may obtain a copy of ourprivacy practices by calling us toll-free at 1-800-767-0700 or by visiting us atwww.uhcsr.com.
Domestic Plan 2011-201728-1: All domestic undergraduate students taking 7 or more units
and all students who are living in the residence halls and are actively attending classes on
campus are required to purchase this insurance plan, unless proof of comparable coverage is
furnished. All domestic graduate students are eligible to enroll in this insurance plan.
International Plan 2011-201728-4: All international students enrolled in 7 or more units,
possessing and maintaining a current passport and valid visa status (F-1, J-1, or M-1, etc.),
engaged in educational activities at the University who are temporarily located outside their
home country and have not been granted permanent residency status are required to
purchase this insurance plan.
All students must actively attend classes for at least the first 31 days after the date for which
coverage is purchased. Home study, correspondence, Internet and television (TV) courses do
not fulfill the Eligibility requirements that the student actively attend classes. The Company
maintains its right to investigate Eligibility or student status and attendance records to verify
that the policy Eligibility requirements have been met. If the Company discovers the Eligibility
requirements 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 or Domestic Partner and unmarried children under 19 years of age or 25 years
if a full-time student at an accredited institution of higher learning who are not self-
supporting. See the Definitions section of the Brochure for the specific requirements
needed to meet Domestic Partner eligibility.
Dependent Eligibility expires concurrently with that of the Insured student.
Effective and Termination Dates
The Master Policy on file at the school becomes effective at 12:01 a.m. August 1, 2011. The
individual student’s coverage becomes effective on the first day of the period for which
premium is paid or the date the enrollment form and full premium are received by the
Company (or its authorized representative), whichever is later. The Master Policy terminates
at 11:59 pm. July 31, 2012. Coverage terminates on that date or at the end of the period
through which premium is paid, whichever is earlier. Dependent coverage will not be
effective prior to that of the Insured student or extend beyond that of the Insured student.
Refunds of premiums are allowed only upon entry into the armed forces.
The Policy is a Non-Renewable One Year Term Policy.
Alternative Coverage - If you do not meet the Eligibility requirements of the Plan, please
call 1-800-980-7395 for information on alternative coverage. This information can also be
accessed at our Web site www.goldenrulehealth.com/studentresources.
Extension of Benefits After Termination
The coverage provided under the Policy ceases on the Termination Date. However, if anInsured is Hospital Confined on the Termination Date from a covered Injury or Sickness forwhich benefits were paid before the Termination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long as the condition continues but not toexceed 30 days after the Termination Date.
The total payments made in respect of the Insured for such condition both before and afterthe Termination Date will never exceed the Maximum Benefit.
After this “Extension of Benefits” provision has been exhausted, all benefits cease to exist,and under no circumstances will further payments be made.
Pre-Admission Notification
UMR Care Management should be notified of all Hospital Confinements prior to admission.
The patient, Physician or Hospital should telephone 1-877-295-0720 at least fiveworking days prior to the planned admission.
patient’s representative, Physician or Hospital should telephone 1-877-295-0720within two working days of the admission to provide the notification of any admissiondue to Medical Emergency.
UMR Care Management is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m.,
C.S.T., Monday through Friday. 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.
Schedule of Medical Expense Benefits
Plan I (2011-201728-1) Domestic Student: Up To $50,000 Maximum Benefit
(For each Injury or Sickness)
Deductible $150 (Per Insured Person) (Per Policy Year)
Plan II (2011-201728-4) International Student: Up To $50,000 Maximum Benefit
(For each Injury or Sickness)
Deductible $150 (Per Insured Person) (Per Policy Year)
The Policy provides benefits for the Usual & Customary Charges incurred by an InsuredPerson for loss due to a covered Injury or Sickness up to the Maximum Benefit of$50,000 for each Injury or Sickness for Domestic Students and $50,000 for each Injuryor Sickness for International Students.
The Preferred Provider for this plan is UnitedHealthcare Options PPO.
If care is received from a Preferred Provider, any Covered Medical Expenses will be paidat the Preferred Provider level of benefits. If the Covered Medical Expense is incurred dueto a Medical Emergency, benefits will be paid at the Preferred Provider level of benefits.
In all other situations, reduced or lower benefits will be provided when on Out-of-Networkprovider is used.
Exclusion #11 for hearing aids will be waived and benefits paid for hearing aids for acovered Injury or Sickness as noted below in the Durable Medical Equipment benefit listed.
Exclusion #15 for Injury or Sickness outside the United States will be waived and benefitspaid for Covered Medical Expenses incurred by students traveling outside the UnitedStates for a school sponsored event or program.
All benefit maximums are combined Preferred Provider and Out-of-Network, unless notedbelow. Benefits will be paid up to the Maximum Benefit for each service as scheduledbelow. Covered Medical Expenses include: PA = Preferred Allowance max = Maximum U&C = Usual and Customary
Room and Board Expense, daily semi-private 80% of PA
room rate; general nursing care provided by the Hospital Miscellaneous Expense, such as the 80% of PA
cost of the operating room, laboratory tests, x-rayexaminations, anesthesia, drugs (excluding takehome drugs) or medicines, therapeutic services,and supplies. In computing the number of dayspayable under this benefit, the date of admissionwill be counted, but not the date discharge.
Routine Newborn Care, while Hospital Confined and
routine nursery care provided immediately after birth.
Surgeon’s Fees, in accordance with data provided by 80% of PA
FAIR Health, Inc. If two or more procedures areperformed through the same incision or in immediatesuccession at the same operative session, the maximumamount paid will not exceed 50% of the secondprocedure and 50% of all subsequent procedures.
Assistant Surgeon
Anesthetist, professional services administered in 80% of PA
Registered Nurse’s Services, private duty nursing care. 80% of PA
Physician’s Visits, benefits do not apply when 80% of PA
Pre-Admission Testing, payable within 3 working 80% of PA
Psychotherapy, benefits are limited to one visit per 80% of PA
day. Psychiatric Hospitals are not covered.
($500 max per day/30 days max Per Policy Year)(Combined Inpatient and Outpatient Benefitsinclude Physician visits for Psychotherapy andpsychological testing, limited to $40 per visitmax/30 days max Per Policy year maximum forinpatient and outpatient.) Severe Mental Illness
See Benefits for Severe Mental Illness & OUTPATIENT
Surgeon’s Fees, in accordance with data provided by 80% of PA
FAIR Health, Inc. If two or more procedures are performedthrough the same incision or in immediate successionat the same operative session, the maximum amountpaid will not exceed 50% of the second procedure and50% of all subsequent procedures.
Day Surgery Miscellaneous, related to scheduled 80% of PA
surgery performed in a Hospital, including the cost ofthe operating room; laboratory tests and x-rayexaminations, including professional fees;anesthesia; drugs or medicines; and supplies. Usualand Customary Charges for Day SurgeryMiscellaneous are based on the Outpatient SurgicalFacility Charge Index.
Assistant Surgeon
Anesthetist, professional services administered in 80% of PA
Physician’s Visits
Physiotherapy, 24 visits max Per Policy Year. 80% of PA
Benefits are limited to one visit per day. Medical Emergency Expenses, the $100 copay/ 80% of PA / $100
Deductible per visit will be waived if admitted. copay per visit Attending Physician's charges, x-rays, laboratory procedures, injections, use of the emergency roomand supplies. Treatment must be rendered within 72hours from time of Injury or first onset of Sickness.
Diagnostic X-ray and Laboratory Services
Tests & Procedures, diagnostic services and 80% of PA
medical procedures performed by a Physician, otherthan Physician’s Visits, Physiotherapy, X-Rays andLab Procedures.
Chemotherapy & Radiation Therapy
Injections, when administered in the Physician’s 80% of PA
office, and charged on the Physician’s statement.
Prescription Drugs, $500 maximum Per Policy Year. UnitedHealthcare
(Mail order Prescription Drugs through UHPS at 2.5 Network Pharmacy times the retail copay up to a 90 day supply subject (UHPS) / 20% to the Prescription Drug Maximum Benefit.) coinsurance perprescription/ up toa 31 day supply perprescription Psychotherapy, benefits are limited to one visit per 80% of PA
day. Including all related or ancillary charges incurredas a result of Mental & Nervous Disorder.
(Inpatient and Outpatient Benefits include Physicianvisits for Psychotherapy and psychological testing,limited to $40 per visit maximum /30 visits maximumPer Policy Year maximum for inpatient and outpatient.) Severe Mental Illness
See Benefits for Severe Mental Illness & Preferred
Ambulance Services, $500 max Per Policy Year.
Durable Medical Equipment, $5,000 max Per
Policy Year. A written prescription must accompanythe claim when submitted. (Benefit includes rental or purchase of DME includinghearing aids, dialysis equipment and supplies.
Replacement equipment is covered.) Consultant, when requested and approved by the
Dental Treatment, $500 max Per Policy Year, made
necessary by Injury to Natural Teeth.
Alcoholism/Drug Abuse
(Inpatient based care: $500 max per day / 45 daysmax Per Policy Year) (Inpatient and outpatientPhysician visits: $40 per visit max / 50 visits max PerPolicy Year.) Maternity, (Pregnancy will not be considered a Pre-
Complications of Pregnancy
Home Health Care, 100 visits max Per Policy Year.
Skilled Nursing Facility, benefits payable for semi-
private room, service and supplies are limited to 100days maximum Per Policy Year.
Hospice Care, benefits payable for inpatient or
outpatient services for Insured Persons with up to oneyear life expectancy.
Home Infusion Therapy,
medication, ancillary services & supplies; caregiver training & visits by the provider to monitor therapy,Durable Medical Equipment and lab services.
Preventive Care, benefits provided for ages 19 &
older; includes routine physical exams, immunizations and diagnostic X-rays & Lab for routine physical exam.
Blood Transfusions, Blood Processing, includes
the cost of unreplaced blood and blood products.
Autologous Blood, benefits payable for self-donated
blood collection, testing, processing and storage forplanned surgery.
Physical Medicine & Occupational Therapy
Speech Therapy
(Outpatient Speech Therapy as a result of a coveredInjury or Sickness.) Prosthetic Devices, benefits payable for surgical
implants, artificial limbs or eyes, and the first pair ofcontact lenses or eyeglasses when required as aresult of eye surgery.
Upper or Lower Jawbone Surgery
($30 max per visit / 12 visits max Per Policy Year; fortreatment of disease, Sickness or Injury.) Routine Well-Child Care
(Birth to 18) (Benefits paid for the following services limited to one provider per visit for all servicesrendered: 1) periodic health evaluations; 2)immunizations, including Hepatitis B and VaricellaZoster; and 3) laboratory services in connectiontherewith.) HIV Testing, (Benefits will be paid for HIV testing
approved by federal Food and Drug Administration andrecommended by US Public Health Servicesregardless of whether the test is related to a primaryHIV diagnosis.) PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM

Preferred Provider Information
"Preferred Providers" are the Physicians, Hospitals and other health care providers who
have contracted to provide specific medical care at negotiated prices. Preferred Providers
in the local school area is UnitedHealthcare Options PPO network.
The availability of specific providers is subject to change without notice. Insured's should
always confirm that a Preferred Provider is participating at the time services are required by
calling the Company at 1-800-767-0700 and/or by asking the provider when making an
appointment for services.
"Preferred Allowance" means the amount a Preferred Provider will accept as payment in
full for Covered Medical Expenses.
"Out of Network" providers have not agreed to any prearranged fee schedules. Insured's
may incur significant out-of-pocket expenses with these providers. Charges in excess of the
insurance payment are the Insured's responsibility.
Regardless of the provider, each Insured is responsible for the payment of their Deductible.
The Deductible must be satisfied before benefits are paid. The Company will pay according
to the benefit limits in the Schedule of Benefits.
Inpatient Hospital Expenses
PREFERRED HOSPITALS - Eligible inpatient Hospital expenses at a Preferred Hospital
will be paid at 80%, up to any limits specified in the Schedule of Benefits. Call (800) 767-
0700 for information about Preferred Hospitals.
OUT-OF-NETWORK HOSPITALS - If care is provided at a Hospital that is not a Preferred
Provider, eligible inpatient Hospital expenses will be paid according to the benefit limits in
the Schedule of Benefits.
Outpatient Hospital Expenses
Preferred Providers may discount bills for outpatient Hospital expenses. Benefits are paid
according to the Schedule of Benefits. Insureds are responsible for any amounts that
exceed the benefits shown in the Schedule, up to the Preferred Allowance.
Professional & Other Expenses
Benefits for Covered Medical Expenses provided by UnitedHealthcare Options PPO
network will be paid at the coinsurance percentages specified on the Schedule of Benefits
or up to any limits specified in the Schedule of Benefits. All other providers will be paid
according to the benefit limits in the Schedule of Benefits.
Medical Emergency
For the purposes of PPO Coverage, Medical Emergency shall include Active Labor. ActiveLabor means a labor at a time at which either of the following would occur: 1) There isinadequate time to effect safe transfer to another hospital prior to delivery. 2) A transfer maypose a threat to the health and safety of the Insured or the unborn child.
UnitedHealthcare Network Pharmacy Benefits
Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL)when dispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supplylimits (up to 31 days) and coinsurance that vary depending on which tier of the PDL theoutpatient drug is listed. There are a few Prescription Drugs that require your Physician tonotify us to verify their use is covered within your benefit.
You are responsible for paying the applicable coinsurance. Your coinsurance is determinedby the tier to which the Prescription Drug is assigned on the PDL. Tier status may changeperiodically and without prior notice to you. Please access www.uhcsr.com or call 1-877-417-7345 for the most up-to-date tier status.
20% coinsurance per prescription up to a 31 day supply per prescription.
Your maximum allowed benefit is $500 Per Policy Year.
Please present your ID card to the network pharmacy when the prescription is filled.
If you do not present the card, you will need to pay the prescription and then submit areimbursement form for prescriptions filled at a network pharmacy along with the paidreceipt in order to be reimbursed. To obtain reimbursement forms, or for information aboutmail-order prescriptions or network pharmacies, please visit www.uhcsr.com and log in toyour online account or call 1-877-417-7345. When prescriptions are filled at phamacies outside the network, the Insured must pay forthe prescriptions out-of-pocket and submit the receipts for reimbursement toUnitedHealthcare StudentResources, P.O. Box 809025, Dallas, TX 75380-9025. See theSchedule of Benefits for the benefits payable at out-of-network pharmacies.
Maternity Testing
This policy does not cover routine, preventive or screening examinations or testing unless
Medical Necessity is established based on medical records. The following maternity routine
tests and screening exams will be considered if all other policy provisions have been met:
Initial screening at first visit – Pregnancy test: Urine human chorionic gonatropin (HCG),
Asymptomatic bacteriuria: Urine culture, Blood type and Rh antibody, Rubella, Pregnancy-
associated plasma protein-A (PAPPA) (first trimester only), Free beta human chorionic
gonadotrophin (hCG) (first trimester only), Hepatitis B: HBsAg, Pap smear, Gonorrhea: Gc
culture, Chlamydia: chlamydia culture, Syphilis: RPR, HIV: HIV-ab; and Coombs test; Each
– Urine analysis; Once every trimester – Hematocrit and Hemoglobin; Once during
first trimester
– Ultrasound; Once during second trimester – Ultrasound (anatomy
scan); Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen test Alpha-fetoprotein
(AFP), Estriol, hCG, inhibin-a; Once during second trimester if age 35 or over -
Amniocentesis or Chorionic villus sampling (CVS); Once during second or third
– 50g Glucola (blood glucose 1 hour postprandial); and Once during third
- Group B Strep Culture. Pre-natal vitamins are not covered. For additional
information regarding Maternity Testing, please call the Company at 1-800-767-0700.
Excess Provision
Even if you have other insurance, the Plan may cover unpaid balances, Deductibles and pay
those eligible medical expenses not covered by other insurance.
Benefits will be paid on the unpaid balances after your other insurance has paid. No
benefits are payable for any expense incurred for Injury or Sickness which has been
paid or is payable by other valid and collectible insurance except for automobile medical
payment insurance.
However, this Excess Provision will not be applied to the first $100 of Covered Medical
Expenses incurred.
Covered Medical Expenses exclude amounts not covered by the primary carrier due to
penalties imposed as a result of the Insured’s failure to comply with policy provisions or
Important: The Excess Provision has no practical application if you do not have other
medical insurance or if your other insurance does not cover the loss.
Accidental Death & Dismemberment Benefit
Loss of Life, Limb or Sight
If such Injury shall independently of all other causes and within 180 days from the date of
Injury solely result in any one of the following specific losses, the Insured Person or
beneficiary may request the Company to pay the applicable amount below. Payment under
this benefit will not exceed the policy Maximum Benefit.
For Loss of:
Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or armsand feet or legs, dismemberment by severance at or above the wrist or ankle joint; withregard to eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater)resulting from any one Injury will be paid.
Mandated Benefits
Benefits for Severe Mental Illnesses and Serious Emotional Disturbances
Benefits will be paid the same as any other Sickness for the diagnosis and MedicallyNecessary treatment of Severe Mental Illnesses of an Insured of any age and of SeriousEmotional Disturbances of an Insured child as specified below: (1) Outpatient services.
(2) Inpatient hospitalization services. (3) Partial hospitalization services.
(4) Prescription Drugs, if the policy includes coverage for Prescription Drugs.
"Severe Mental Illness" includes: (1) Schizophrenia.
(2) Schizoaffective disorder.
(3) Bipolar disorder (manic-depressive disorder)(4) Major depressive disorders.
(5) Panic disorder.
(6) Obsessive-Compulsive disorder.
(7) Pervasive developmental disorder of Autism.
(8) Anorexia nervosa.
(9) Bulimia nervosa.
"Serious emotional disturbance of a child" means a child under the age of 18 years who has
one or more mental disorders as identified in the most recent edition of the Diagnostic and
Statistical Manual of Mental Disorders
, other than a primary substance use disorder or
developmental disorder, that result in behavior inappropriate to the child's age according to
expected developmental norms. Members of this target population must meet one or more
of the following criteria:
(A) As a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, orability to function in the community; and either of the following occur: (i) the child isat risk of removal from home or has already been removed from the home. (ii) Themental disorder and impairments have been present for more than 6 months or arelikely to continue for more than one year without treatment.
(B) The child displays one of the following: psychotic features, risk of suicide or risk of (C) The child meets special education eligibility requirements under Chapter 26.5 of division 7 of Title 1 of the Government Code.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Additional Benefits
Benefits are provided as mandated by California Department of Insurance such as Benefitsfor Diabetes, Telemedicine, AIDS Vaccine, Phenylketonuria (PKU), Osteoporosis, CancerClinical Trials, Breast Cancer Screening and Treatment, Mammography, Upper or LowerJawbone Surgery, Reconstructive Surgery, Prosthetic Devices for Speaking PostLaryngectomy, Prostate Cancer Screening, Cancer Screening Tests, and Cervical CancerScreening. A detail of these benefits may be found in the Master Policy on file at theUniversity.
Creditable Coverage means any individual or group policy, contract or program, that is
written or administered by a disability insurance company, health care service plan, fraternal
benefit society, self-insured employer plan, or any other entity, in this state or elsewhere, and
that arranges or provides medical, hospital, and surgical coverage not designed to
supplement other private or governmental plans, including Medicare or Medicaid, nonprofit
medical and surgical plan or hospital service plan that provides similar benefits, Armed
Forces Personnel Medical and Dental Care, Indian Health Service or tribal organization
medical care program, a state health benefits risk pool, Federal Employees Health Benefit
Plan, the Peace Corps Act health benefit plan, health maintenance organization, a public
health plan, or College Plan. The term includes continuation or conversion coverage, but
does not include accident only, credit, coverage for on site medical clinics, disability income,
Medicare supplement, long-term care insurance, dental, vision, coverage issued as a
supplement to liability insurance, insurance arising out of a workers' compensation or similar
law, automobile medical payment insurance, or insurance under which benefits are payable
with or without regard to fault and that is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance.
Domestic Partner Domestic partners are two adults who have chosen to share one
another's lives in an intimate and committed relationship of mutual caring and where all of
the following requirements are met: (1) Both persons have a common residence. 2) Neither
person is married to someone else or is a member of another domestic partnership with
someone else that has not been terminated, dissolved, or adjudged a nullity. (3) The two
persons are not related by blood in a way that would prevent them from being married to
each other in this state. (4) Both persons are at least 18 years of age. (5) Either of the
following (A) Both persons are members of the same sex. (B) One or both of the persons
meet the eligibility criteria under Title II of the Social Security Act as defined in 42 U.S.C.
Section 402(a) for old-age insurance benefits or Title XVI of the Social Security Act as
defined in 42 U.S.C. Section 1381 for aged individuals. Notwithstanding any other provision
of this section, persons of opposite sexes may not constitute a domestic partnership unless
one or both of the persons are over the age of 62. (6) Both persons are capable of
consenting to the domestic partnership.
Pre-Existing Condition means any condition for which medical advice, diagnosis, care or
treatment, including the use of Prescription Drugs is recommended or received from a
Physician within 6 months immediately prior to the Insured's Effective Date under the policy.
Sickness means sickness or disease of the Insured Person which causes loss 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, contributed to, or resulting from;or b) treatment, services or supplies for, at, or related to: 1. Addiction, such as nicotine addiction;2. Biofeedback;3. Chronic pain disorders;4. 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; 5. Custodial care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or custodial care; 6. Dental treatment, except for accidental Injury to Natural Teeth; 7. Elective Surgery or Elective Treatment; 8. Elective abortion;9. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visualdefects and problems; except when due to a disease process; 10. Health spa or similar facilities; strengthening programs; 11. Hearing examinations or hearing aids; 12. Hirsutism; alopecia;13. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury or as specificallyprovided in the policy; 14. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 15. Injury or Sickness outside the United States and its possessions, except for a Medical Emergency when traveling for academic study abroad programs, business orpleasure; 16. Injury sustained while (a) participating in any intercollegiate or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as aparticipant; or (c) while participating in any practice or conditioning program for suchsport, contest or competition; 18. Lipectomy;19. Nuclear, chemical or biological Contamination, whether direct or indirect.
“Contamination” means the contamination or poisoning of people by nuclear and/orchemical and/or biological substances which cause Sickness and/or death; 20. Organ transplants, including organ donation; 21. Participation in a riot or civil disorder; commission of or attempt to commit a felony; 22. Pre-Existing Conditions, except for individuals who have been continuously insured for at least 6 consecutive months under any health insurance plan or policy or employer-provided health benefit arrangement. Credit for time served will be given whencovered under Creditable Coverage provided the individual becomes eligible andenrolls under this policy within 63 days of termination of the prior plan; 23. Prescription Drug Services - no benefits will be payable for: a) Therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use, exceptas specifically provided in the Benefits for Diabetes; b) Immunization agents, biological sera, blood or blood products administered on an c) Drugs labeled, “Caution - limited by federal law to investigational use” or d) Products used for unapproved cosmetic indications;e) Drugs used to treat or cure baldness, and anabolic steroids used for body building;f) Anorectics - drugs used for the purpose of weight control;g) Fertility agents, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, or h) Growth hormones; ori) Refills in excess of the number specified or dispensed after one (1) year of date of 24. Reproductive/Infertility services including but not limited to: fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or withthe intent of inducing conception; premarital examinations; impotence, organic orotherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversal ofsterilization procedures; 25. Research or examinations relating to research studies, or any treatment for which the patient or the patient’s representative must sign an informed consent documentidentifying the treatment in which the patient is to participate as a research study orclinical research study; 26. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specificallyprovided in the policy; 27. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 28. Supplies, except as specifically provided in the policy;29. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; 30. Treatment in a Government hospital, unless there is a legal obligation for the Insured 31. 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 notcovered); and 32. Weight management, weight reduction, nutrition programs, treatment for obesity, (except surgery for morbid obesity), surgery for removal of excess skin or fat, exceptas specifically provided in the policy.
Collegiate Assistance Program
Insured Students have access to nurse advice, health information, and counseling support24 hours a day, 7 days a week by dialing the number indicated on the permanent ID card.
Collegiate Assistance Program is staffed by Registered Nurses and Licensed Clinicianswho can help students determine if they need to seek medical care, need legal/financialadvice or may need to talk to someone about everyday issues that can be overwhelming.
Scholastic Emergency Services: Global Emergency Medical Assistance
If you are a student insured with this insurance plan, you and your insured spouse or
Domestic Partner and minor child(ren) are eligible for SES services. The requirements to
receive these services are as follows:
International Students, insured spouse or Domestic Partner and insured minor child(ren):
You are eligible to receive SES services worldwide, except in your home country.
Domestic Students, insured spouse or Domestic Partner and insured minor child(ren): You
are eligible for SES services when 100 miles or more away from your campus address and
100 miles or more away from your permanent home address or while participating in a
Study Abroad program.
SES services include Emergency Medical Evacuation and Return of Mortal Remains that
meet the U.S. visa requirements. The Emergency Medical Evacuation services are not
meant to be used in lieu of or replace local emergency services such as an ambulance
requested through emergency 911 telephone assistance. All SES services must be
arranged and provided by SES, Inc. any services not arranged by SES, Inc. will not be
considered for payment.
Key Services include:
* Care for Minor Children Left Unattended Due to a Medical Incident, Please log into your online account www.uhcsr.com for additional information on SES
Global Emergency Assistance Services, including service descriptions and program
exclusions and limitations.
To access services please call:
(877) 488-9833 Toll-free within the United States
(609) 452-8570 Collect outside the United States
Services are also accessible via e-mail at medservices@assistamerica.com.
When calling the SES Operations Center, please be prepared to provide:
1. Caller's name, telephone and (if possible) fax number, and relationship to the 2. Patient's name, age, sex, and Reference Number;3. Description of the patient's condition;4. Name, location, and telephone number of hospital, if applicable;5. Name and telephone number of the attending physician; and6. Information of where the physician can be immediately reached.
SES is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan andare subject to the policy limits of your health coverage. All assistance services must bearranged and provided by SES, Inc. Claims for reimbursement of services not provided bySES will not be accepted. Please refer to your SES brochure or Program Guide atwww.uhcsr.com for additional information, including limitations and exclusions pertaining tothe SES program.
Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status,
Explanation of Benefits, correspondence and coverage information via My Account at
www.uhcsr.com. Insured can also print a temporary ID card, request replacement ID card
and locate network provider from My Account.
If you don’t already have an online account, simply select the “Create an Account” link from
the home page at www.uhcsr.com. Follow the simple, onscreen directions to establish an
online account in minutes. Note that you will need your 7-digit insurance ID number to
create an online account. If you already have an online account, just log in from
www.uhcsr.com to access your account information.
Claim Procedure
In the event of Injury or Sickness, students should: 1) Report to the Student Health Service or Infirmary for treatment or referral, or when not in school, 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 theUniversity under which the student is insured. A Company claim form is notrequired for filing a claim.
3) File Claim within 30 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 yearwill not be considered for payment except in the absence of legal capacity.
The Plan is Underwritten by:
Submit All Claims or Inquiries to:
UnitedHealthcare StudentResources
For general information on benefits, eligibility and enrollment, student ID Cards, or service Gallagher Koster
If you need medical attention before the ID card is received, benefits will be payableaccording to the Policy. You do not need an ID card to be eligible to receive benefits. CallGallagher Koster to verify eligibility.
Please keep this Brochure as a general summary of the insurance. The Master Policy onfile at the University contains all of the provisions, limitations, exclusions and qualificationsof your insurance benefits, some of which may not be included in this Brochure. The MasterPolicy is the contract and will govern and control the payment of benefits.
This Brochure is based on Policy numbers: 2011-201728-1 and 2011-201728-4

Source: https://hiu.edu/studentlife/health/11-12StuHealthInsuranceBrochure.pdf


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