COMPASS - Affordable health insurance plans for international students in America

Table of contents

1. Rates
2. Summary schedule of benefits
3. Medical expense benefits
4. Repatriation expense
5. Medical evacuation
6. Accidental Death & Dismemberment
7. Eligibility
8. Period of coverage
9. Definitions
10. Exclusions
11. How to enroll by fax or mail
12. Assistance services
13. Claim procedure
14. Refund of premium
15. Underwriter
16. Preferred Provider Organization (PPO)

3. Medical expense benefits

When a covered Injury or Sickness requires treatment by a Physician, the policy will provide benefits for the Usual and Customary Charges for Medically Necessary Covered Medical Expenses, which exceed the deductible per person for each Injury or Sickness. Payment for any Covered Medical Expense will be no more than the Benefit Limit shown for it. The total payable for all Covered Medical Expenses will be no more than the Maximum Benefit Limit per Sickness or Injury. Benefits are subject to the Excess Provision.

Covered Expenses are the Usual and Customary charges for medically necessary services and supplies incurred within 13 weeks from the date of the accident causing the injury or the onset of sickness. Treatment must begin no more than 30 days after the date of the accident or the onset of sickness.

Covered medical expenses include:

1. Room and Board Expense: 1) daily semi-private room rate when Hospital Confined; and 2) general nursing care provided and charged for by the Hospital. $1,000/day to 30 days maximum.
2. Hospital Miscellaneous Expenses: 1) while Hospital Confined; or 2) for pre-admission expenses for being Hospital Confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; X-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies. $500 per day, 30 days maximum.
3. Intensive Care. Additional $525/day to 8 days maximum.
4. Physiotherapy (Inpatient). $35 per visit, 1 visit/day, 12 visits maximum.
5. Surgery: Physician's fees for Inpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this Inpatient surgery benefit; or under the Outpatient surgery benefit, but not for both. $3,000 maximum.
6. Anesthetist Services: in connection with Inpatient surgery. 25% of Surgery maximum.
7. Assistant Surgeon (Inpatient): 25% of Surgery Maximum.
8. Private Duty Nurse Services: 1) private duty nursing care only; 2) while Hospital Confined; 3) ordered by a licensed Physician; and 4) a Medical Necessity. $500 maximum. General nursing care provided by the Hospital is not covered under this benefit.
9. Physician Visits when Hospital Confined. Benefits are limited to one Physician's visit per day. Benefits do not apply when related to surgery. $60 per visit for COMPASS Gold and $50 per visit for COMPASS Silver, 1 visit/day, 30 visits maximum. Covered medical expenses will be paid under the Inpatient benefit or under the Outpatient benefit for Physician's Visits but not both.
10. Pre-admission Testing within 7 days before Hospital admission: limited to routine tests such as: complete blood count; urinalysis; and chest X-ray. $900 maximum. If otherwise payable under the policy, major diagnostic procedures such as: CAT scans; NMR's; and blood chemistries will be paid under the "Hospital Miscellaneous" benefit.
11. Mental and Nervous Disorder (Inpatient): the benefits and the maximum amounts are specified in the Schedule of Benefits and are the same as any Sickness. Benefits are limited to one Physician's visit per day.
12. Surgery (Outpatient): Physician's fees for Outpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this Outpatient surgery benefit; or under the Inpatient surgery benefit, but not both. $3,000 maximum.
13. Day Surgery Miscellaneous (Outpatient): in connection with Outpatient day surgery; excluding non-scheduled surgery and surgery performed in a Hospital emergency room, trauma center, Physician's office, or clinic. Benefits will be paid for services and supplies such as: the cost of the operating room, laboratory tests and X-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies. $1,000 maximum.
14. Anesthetist (Outpatient): in connection with Outpatient surgery. 25% of Surgery maximum.
15. Assistant Surgeon (Outpatient): 25% of Surgery Maximum.
16. Physiotherapy (Outpatient): $35 per visit, 1 visit/day, 12 visits maximum.
17. Physician Visits (Outpatient): Includes injections administered during visit. Benefits do not apply when related to surgery or Physiotherapy. $60 per visit for COMPASS Gold and $50 per visit for COMPASS Silver, 1 visit/day, 30 visits maximum. Covered medical expenses will be paid under the Outpatient benefit or under the Inpatient benefit for Physician's visits but not both.
18. Diagnostic X-rays & Lab services (Outpatient): $400 maximum. Cat Scan, PET Scan or MRI up to $250 additional.
19. Medical Emergency Expenses (Outpatient): only in connection with a Medical Emergency as defined. Benefits will be paid for the use of the emergency room and supplies. 75% of Usual and Customary to $300 maximum.
20. Radiation Therapy and or Chemotherapy (Outpatient), $1,000 maximum.
21. Prescription Drugs (Outpatient). $100 maximum.
22. Mental and Nervous Disorder (Outpatient): the benefits and the maximum amounts are specified in the Schedule of Benefits and are the same as any Sickness. Benefits are limited to one Physician's visit per day.
23. Ambulance Service. $400 maximum.
24. Braces and Appliances: 1) when prescribed by a Physician; and 2) a written prescription accompanies the claim when submitted. Replacement braces and appliances are not covered. Braces and appliances include durable, medical equipment which is equipment that: 1) is primarily and customarily used to serve a medical purpose; 2) can with stand repeated use; and 3) generally is not useful to a person in the absence of Injury or Sickness. $1,000 maximum. No benefits will be paid for rental charges in excess of purchase price.
25. Consultant Physician Fees (Inpatient): when requested and approved by the attending Physician. $400 maximum.
26. Dental Treatment: 1) performed by a Physician; and 2) made necessary by Injury to Sound, Natural Teeth. $500 maximum. Routine dental care and treatment to the gums are not covered.
27. Alcoholism/Drug Abuse Treatment: the benefits and the maximum amounts are specified in the Schedule of Benefits and are the same as any Sickness.
28. Maternity (conception must occur while coverage is in force): $7,500 maximum for normal delivery; $10,000 for C-section delivery for COMPASS Gold. $5,000 maximum for normal delivery; $7,500 for C-section delivery for COMPASS Silver.
29. Benefits are payable only for those Covered Medical Expenses incurred while the policy is in effect for the Insured Person. No benefits are payable for any expenses incurred after the date insurance terminates, except if an Insured Person is hospitalized on the date his insurance terminates. Benefits will continue to be paid until the completion of the hospital stay, but not to exceed a period of 31 days from the termination date, or the Maximum Policy Benefit, whichever occurs first.
30. Any child conceived on or after the effective date and born of insured will be covered under the policy for the first 31 days after birth. Coverage for such child will be for injury or Sickness including medically diagnosed congenital defects, birth abnormalities, prematurity, and nursery care when the child is sick or injured. To continue coverage beyond 31 days, written application and payment of any required premium must be made to International Student Organization and forwarded to the Underwriting Company.

Excess Provision: All benefits shall be in excess of all other valid and collectible insurance and shall apply only when such benefits are exhausted. If an Insured's Injury or Sickness is due to an act or omission of another, benefits payable by this plan are subject to recovery from amounts eventually paid to the Insured by or on behalf of, the other person.

Conformity With State Statutes: Any provision of the Policy which, on its effective date, is in conflict with the statutes of the state in which it is issued, is hereby amended to conform to the minimum requirements of such statutes.

4. Repatriation expense

If the Insured dies prior to his/her termination of coverage under the policy, benefits will be paid up to a maximum of $25,000 for: a) cost of embalming; b) coffin; c) transportation of the body to the Insured's home country/country of permanent residence. This benefit does not include the transportation expense of anyone accompanying the deceased.

5. Medical evacuation

Benefits will be paid for covered expenses up to a maximum of $50,000 if any Injury or Sickness commencing during the period of coverage results in the necessary emergency evacuation of the Insured. An emergency evacuation must be ordered by a legally licensed physician who certifies that the severity of the Insured's Injury or Sickness warrants the emergency evacuation.

6. Accidental Death & Dismemberment

Accidental Death Benefit

If Injury to the Insured results in death within 365 days of the date of the accident that caused the injury, the Company will pay 100% of the Maximum Amount.

Accidental Dismemberment Benefit

If Injury to the Insured results, within 365 days of the date of the accident that caused the Injury, in any one of the Losses specified below, the Company will pay the percentage of the Maximum Amount shown below for that Loss:

7. Eligibility

You are eligible if you have a current passport or visa and are temporarily residing outside your home country/country of permanent residence, while actively engaged in education or research activities. You are "actively engaged" in educational activity if you are:

• F1/J1 valid visa holder.
• Undergraduate - registered for and attending classes for twelve (12) or more credit hours.
• Graduate student.
• Scholar or researcher who is invited by an educational organization.
• Student involved in education, educational activities, or research- related activities.

Your spouse and any dependent children under the age of 19 are also eligible for coverage if accompanying you. For purposes of this insurance, if your home country (passport country) is different from your country of permanent residence (location in which you permanently reside), you will not be covered in either location.

8. Period of coverage

Coverage will begin at 12:01 am on the latest of the following:

1. The date of departure from your home country/country of permanent residence;
2. The date the application form and premium are received by the Underwriting Company or its designated representative; or
3. The date requested on the application form.

Coverage will terminate on the earliest of the following:

1. The date of return to your home country/country of permanent residence;
2. The date you are no longer eligible for this insurance; or
3. The last day for which premium has been paid; or
4. The date the Policy terminates (unless the Company and Policyholder agree, in writing, to permit coverage to continue to the end of the period for which premiums have been paid in lieu of a return of unearned premium); or
5. The date of entry into active duty military service.

9. Definitions

HOSPITAL means a licensed or properly accredited general Hospital which; 1) is open at all times; 2) is operated primarily and continuously for the treatment of and surgery for sick and injured person as inpatients; 3) is under the supervision of a staff of one or more legally qualified Physicians available at all times; 4) continuously provides on the premises 24 hour nursing service by Registered Nurses; 5) provides organized facilities for diagnosis and major surgery on the premises; and 6) is not primarily a clinic, nursing, rest or convalescent home, or an institution specializing in or primarily treating Mental and Nervous Disorders.

INJURY means bodily Injury: 1) directly and independently caused by specific accident which is unrelated to any pathological, functional, or structural disorder or Injury; 2) treated by a Physician within 30 days after the date of accident; and 3) which causes loss during the term of the policy.

PRE-EXISTING CONDITION means any injury or illness which was contracted or which manifested itself, or for which treatment or medication was prescribed, prior to the effective date of this insurance as to the Insured.

SICKNESS means Sickness or disease of the Insured Person which causes loss, and originates while the Insured Person is covered under the policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness.

USUAL AND CUSTOMARY means charges for medical services or supplies essential to the care of the Insured if they are the amount normally charged by the provider for similar services and supplies and do not exceed the amount ordinarily charged by most providers of comparable services and supplies in the locality where the services or supplies are received.

10. Exclusions

No benefits will be paid for loss or expense caused by, contributed to, or resulting from:

1. Pre-existing Conditions; however, a Pre-Existing Condition will be covered after the person has been continuously insured for 6 months under this policy issued to the Policyholder, provided continuous insurance is maintained.
2. No benefits will be paid for loss or expense caused by, enrolling solely for the purpose of obtaining medical treatment, while on a waiting list for a specific treatment, or while traveling against the advice of a Physician;
3. For routine physical or other examination where there are no objective indications or impairment in normal health, and laboratory diagnostic or X-ray examination except in the course of a disability established by the prior call or attendance of a physician;
4. Eye examinations; prescriptions or fitting of eyeglasses and contact lenses; or other treatment for visual defects and problems. "Visual Defects" means any physical defect of the eye which does or can impair normal vision;
5. 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;
6. Dental treatment, except as the result of Injury to Sound, Natural Teeth as stated in the Schedule of Benefits;
7. Professional services rendered by a member of the Insured Person's immediate family, or anyone who lives with the Insured Person;
8. Services or supplies not necessary for the medical care of the patient's Injury or Sickness;
9. Weak, strained or flat feet, corns, calluses, or toenails;
10. Cosmetic surgery, or treatment for congenital anomalies (except a specifically provided), except reconstructive surgery as the result of a covered Injury or Sickness. Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or Sickness;
11. Diagnostic or surgical procedures in connection with infertility unless infertility is a result of a covered Injury or Sickness;
12. Birth control, including surgical procedures and devices;
13. Routine newborn baby care, well-baby nursery, well-baby care, and related Physician charges;
14. Participation in professional or intercollegiate athletics;
15. Injury or Sickness for which benefits are paid or payable under any Worker's Compensation or Occupational Disease Law or Act, or similar legislation;
16. Organ transplants;
17. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rate premium will be refunded upon request for such period not covered);
18. Participation in a riot or civil disorder; commission of or attempt to commit a felony in the country in which it was attempted or committed;
19. Suicide or attempted suicide (including drug overdose) while sane or insane (while sane in Missouri); or intentionally self-inflicted Injury;
20. Charges of an institution, health service, or infirmary for whose service payment is not required in the absence of insurance;
21. Treatment of nervous or mental disorders, except as stated in the Schedule of Benefits, or treatment of alcoholism or drug abuse, except as provided for treatment of mental or nervous disorders, according to the Schedule of Benefits;
22. Loss incurred from riding in any aircraft, other than as a passenger in an aircraft licensed for the transportation of passengers;
23. Duplicate services actually provided by both a certified nurse-midwife and Physician;
24. Expenses payable under any prior policy which was in force for the person making the claim;
25. Expenses incurred during a Hospital emergency room visit which is not of an emergency nature;
26. Expenses incurred for outpatient treatment in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;
27. Medical expense resulting from a motor vehicle accident in excess of that which is payable under any valid and collectible insurance;
28. Pregnancy or childbirth (except when conception occurs while insured hereunder); elective abortion; elective cesarean section; pregnancy or childbirth for a dependent when dependent child of an Insured Student (except for complications arising therefrom);
29. Expenses covered by any other valid and collectible medical, health or accident insurance;
30. Expenses incurred after the date insurance terminates for an Insured Person except as may be specifically provided;
31. Expenses incurred for injuries resulting from the use of alcohol or intoxicants, or any drugs unless prescribed by a Physician;
32. Sexually transmitted diseases;
33. HIV infection, HIV-related illnesses and AIDS;
34. For services, supplies or treatment, including any period of hospital confinement, which were not recommended, approved and certified as necessary and reasonable by a physician;
35. For miscarriage resulting from accident, which exceed $500;
36. For the ordinary cost of a one way airplane ticket used in the transportation back to the Insured's country where an air ambulance benefit is provided;
37. For specific named hazards: motorcycle driving, scuba diving, skiing, mountain climbing, sky diving, professional or amateur racing, and piloting an aircraft;
38. Treatment paid for or furnished under any other individual or group policy, or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government program or facility set up for the treatment without cost to any individual;
39. Treatment of Acne
40. Elective Surgery and Elective Treatment. For details on what is determined to be Elective Surgery and Elective Treatment contact ACI at (888) 293-9229.

11. How to enroll by fax or mail

1. Complete the enrollment form. Answer all questions to avoid delays.
2. Specify the required months of coverage - Minimum 3 months.
3. Multiply number of months by your age-band monthly rate.
4. If you require insurance for your spouse and children, multiply the same number of months for each dependent by the appropriate rate.
5. Total the amounts and please sign the form.
6. Make check payable to ISO.
7. Mail enrollment forms with payment to: ISO, 250 West 49th Street, Suite 806, New York, NY 10019
8. When paying by credit card, please include expiration date. You may fax credit card payments with enrollment form to (212) 262-8920.

12. Assistance services

Assistance services are provided by AIG Assist®, a member company of American International Group, Inc. An outline of the assistance services appears below.

Pre-Travel Assistance

• Help in arranging special medical services needed while traveling

Medical Emergency Services

• Worldwide, 24-hour medical location service
• Medical case monitoring, arrangement of communication between patient, family, physicians, employer, consulate, etc.
• Medical transportation arrangements
• Emergency message service for medical situations

Legal Assistance

• Worldwide, 24-hour contact for non-criminal legal emergencies
• Legal referral to help you locate a consular official or attorney

Travel Assistance

• Help with lost passports, tickets and documents

AIG Assist®

• U.S. or Canada: (800) 626-2427
• International: Contact International Operator to place your call to Houston at (01-713) 267-2525.

13. Claim procedure

In the event of Sickness or Injury, you should report to the Student Health Service, if available, or the nearest physician or hospital. Persons insured under this plan may choose to be treated within or outside of the Beech Street Network. Reimbursement rates will vary according to the source of care as described under the Summary Schedule of Benefits.

Please mail the completed claim form and accompanying documentation to the claims administrator, Administrative Concepts, Inc., 994 Old Eagle School Road Suite 1005, Wayne, PA 19087. The completed claim form, all itemized bills, statements and receipts must be sent to the claims administrator no more than 90 days after a covered loss occurs or end, or as soon after that as is reasonably possible.

Should it become necessary to check upon the status of your filed claim, you may call the claims administrator at (888) 293-9229 between 9:00 A.M. and 5:00 P.M. Monday through Friday or e-mail at aciclaims@visit-aci.com. On line claims status via the internet is available 24 hours a day at www.visit-aci.com.

14. Refund of premium

Unearned funds will be refunded, less a $50 processing fee, for the number of full months only. Premium refunds, less a process fee, will be considered only for entry into the armed forces or if you are not eligible for this insurance under the eligibility requirements. The refund request must be in writing and your Medical Insurance ID card must be returned with your request. Premium refunds will not be considered if a claim has been filed during the Period of Coverage. All refunds are subject to the approval of the administrator.

15. Underwriter

This brochure provides you with a brief summary of COMPASS Gold and COMPASS Silver comprehensive short-term medical insurance plans, as underwritten by The Insurance Company of the State of Pennsylvania, Philadelphia, PA, a Member Company of American International Group (AIG). If any conflict should arise between the contents of these pages and the Policies (GLB 9117173, 9117174) or if any point is not covered herein, the terms of the Policy will govern in all cases.

16. Preferred Provider Organization (PPO)

Persons insured under this plan may choose to be treated within or outside of the Beech Street Network. Reimbursement rates will vary according to the source of care as described under the Summary Schedule of Benefits. Insured's can call Beech Street toll free at (800) 432-1776 to search for participating doctors or hospitals Monday through Friday, 8:00 A.M. to 8:00 P.M. Eastern Standard Time, or they can access Beech Street on the internet at:www.beechstreet.com.