ISO Med - Affordable health insurance plans for international students

Table of contents

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

3. 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 one of the following:

1. F1/J1 valid visa holder and you have not applied for permanent residency.
2. Undergraduate - registered for and attending classes on a full-time basis.
3. Graduate student.
4. Scholar or researcher who is invited by an educational organization.
5. Student involved in education, educational activities, or research related activities.

Your Dependents, spouse and/or Child(ren) (under the age of 19, 25 if a full-time student), are also eligible for coverage under this Policy 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. Permanent residents are not eligible for coverage under this Policy.

4. Period of coverage

EFFECTIVE DATE OF INSURANCE

Insurance for an Eligible Person who enrolls within 31 days after he or she becomes eligible is effective on the latest of the following dates:

1. the date We receive the completed enrollment form, if any;
2. the date the required premium is paid; or
3. the date of the scheduled Trip departure date.

TERMINATION DATE OF INSURANCE

An Insured's coverage will end on the earliest of the following dates:

1. the policy terminates;
2. the Insured is no longer eligible;
3. the period ends for which premium is paid;
4. the insured returns to his or her Home Country
5. the scheduled return trip date.

A Dependent's coverage will end on the earliest of the following dates:

1. he or she is no longer a Dependent;
2. the Insured's coverage ends;
3. the period ends for which premium is paid;
4. the Dependent returns to his or her Home Country
5. the scheduled return trip date.

5. Medical expense benefits

When a Covered Accident or Sickness requires treatment by a Doctor, 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 Covered Accident 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 90 days from the date of the Covered Accident causing the injury or the onset of Sickness. Treatment must begin no more than 30 days after the date of the Covered Accident or the onset of Sickness.

Covered Medical Expenses

1. Hospital Room and Board Expenses: the daily room rate when a Covered Person is Hospital Confined and general nursing care is provided and charged for by the Hospital. In computing the number of days payable under this benefit, the date of admission will be counted but not the date of discharge, maximum 30 days per occurrence.
2. Ancillary Hospital Expenses: services and supplies including operating room, laboratory tests, anesthesia and medicines (excluding take home drugs) when Hospital Confined. This does not include personal services of a non-medical nature. Doctor's surgical expenses are not covered under this expense. Subject to maximum of $3,000 per occurrence under the ISO Med 2 plan only.
3. Daily Intensive Care Unit Expenses: the daily room rate when a Covered Person is Hospital Confined in a bed in the Intensive Care Unit and nursing services other than private duty nursing services.
4. Medical Emergency Care (room and supplies) Expenses: incurred within 72 hours of an Accident and including the attending Doctor's charges, X-rays, laboratory procedures, use of the emergency room and supplies subject to co-payment of $300 per occurrence. If a covered Person is admitted to the hospital following visit to the emergency room, the co-payment is waived.
5. Newborn Nursery Care Expenses.
6. Outpatient Surgical Room and Supply Expenses for use of the surgical facility.
7. Outpatient diagnostic X-rays, laboratory procedures and tests.
8. Doctor Non-Surgical Treatment/Examination Expenses (excluding medicines) including the Doctor's initial visit $60 per visit for ISO Med 1, $40 per visit for ISO Med 2; each Medically Necessary follow-up visit $40 per visit for ISO Med 1, $30 per visit for ISO Med 2 and consultation visits when referred by the attending Doctor, $250 per visit for ISO Med 1, $200 per visit for ISO Med 2.
9. Doctor's Surgical Expense subject to maximum of $3,000 per occurrence.
10. Assistant Surgeon Expenses when Medically Necessary
11. Anesthesiologist Expenses for pre-operative screening and administration of anesthesia during a surgical procedure whether on an inpatient or outpatient basis.
12. Outpatient Laboratory Test Expenses.
13. Physiotherapy Physical Medicine/Chiropractic/Acupuncture Expenses on an inpatient or outpatient basis limited to one visit per day (as shown in the Schedule of Benefits). Expenses include treatment and office visits connected with such treatment when prescribed by a Doctor, including diathermy, ultrasonic, whirlpool, or heat treatments, adjustments, manipulation, massage or any form of physical therapy.
14. X-ray Expenses (including reading charges) but not for dental X-rays.
15. Dental Expenses due to a covered accident including dental x-rays for the repair or treatment of each injured tooth that is whole, sound and a natural tooth at the time of the Accident, and emergency alleviation of dental pain. $300 per tooth for ISO Med 1, $250 per tooth for ISO Med 2.
16. Dental Expenses for impacted wisdom tooth.
17. Outpatient Registered Nurse Services if ordered by a Doctor.
18. Ambulance Expenses for transportation from the emergency site to the Hospital.
19. Rehabilitative braces or appliances prescribed by a Doctor. It must be durable medical equipment that 1) is primarily and customarily used to serve a medical purpose; 2) can withstand repeated use; and 3) generally is not useful to a person in the absence of Injury .No benefits will be paid for rental charges in excess of the purchase price.
20. Prescription Drug Expenses including dressings, drugs and medicines prescribed by a Doctor and administered on an outpatient basis.
21. Medical Equipment Rental Expenses for a wheelchair or other medical equipment that has therapeutic value for a Covered Person. We will not cover computers, motor vehicles or modifications to a motor vehicle, ramps and installation costs, eyeglasses and hearing aids.
22. Medical Services and Supplies: expenses for blood and blood transfusions; oxygen and its administration.
23. Eyeglasses, contact lenses and hearing aids when damage occurs in a Covered Accident that requires medical treatment.
24. Mental and Nervous Disorders: expenses for treatment of a disorder that results directly and from no other cause, from a Covered Accident, while Hospital Confined or on an outpatient basis. Benefits are limited to one treatment per day. "Mental and Nervous Disorders" means Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind.
25. Expenses due to an aggravation or re-Injury of a Pre-Existing Condition.
26. Therapeutic termination of pregnancy.

Excess Provision

We pay Covered Expenses after the Covered Person satisfies any Deductible and only when they are in excess of amounts paid by any other Health Care Plan.
We pay benefits without regard to any Coordination of Benefits provision in any Health Care Plan.

6. Emergency medical evacuation benefit

Benefits will be paid for covered expenses up to the maximum stated in the Summary Schedule of Benefits if an 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. The charges must be Medically Necessary and must be within the usual level of charges for similar transportation, treatment, services, and supplies in the locality where the expense is incurred. All transportation arrangements will be made by the most direct and economical conveyance and route possible.

"Emergency Medical Evacuation" means:

1. The Covered Person's immediate transportation from the place where he or she suffers an Injury or Sickness to the nearest Hospital or other medical facility where appropriate medical treatment can be obtained; or
2. The Covered Person's transportation to his or her Home Country to obtain further medical treatment in a Hospital or other medical facility or to recover after suffering an Injury or Sickness.

All expenses must be authorized in writing or by an authorized electronic or telephonic means in advance.

7. Accidental Death & Dismemberment

If Injury to the Covered Person results, within 365 days of the date of a Covered Accident, in any one of the losses shown below, We will pay the Benefit Amount shown below for that loss. If multiple losses occur, only one Benefit Amount, the largest, will be paid for all losses due to the same Accident.

Covered Loss & Benefit Amount

8. Repatriation of remains benefit

If the Insured dies prior to his/her termination of coverage under the policy due to an Injury or Sickness covered under the policy, benefits will be paid up to the maximum stated in the Summary Schedule of Benefits 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.

All expenses must be authorized in writing or by an authorized electronic or telephonic means in advance.

9. Definitions

Covered Accident means an accident that occurs while coverage is in force for a Covered Person and results directly and independently of all other causes in a loss or Injury covered by the Policy for which benefits are payable.

Covered Person means any Insured and Dependent who enrolls for coverage and for whom the required premium is paid.

Dependent means an Insured's lawful spouse under age 70; or an Insured's unmarried child, from the moment of birth to age 19, 25 if a full-time student, who is chiefly dependent on the Insured for support. A child, for eligibility purposes, includes an Insured's natural child; adopted child, beginning with any waiting period pending finalization of the child's adoption; or a stepchild who resides with the Insured or depends chiefly on the Insured for financial support.

Doctor means a licensed health care provider acting within the scope of his or her license and rendering care or treatment to a Covered Person that is appropriate for the conditions and locality. It will not include a Covered Person or a member of the Covered Person's Immediate Family Member or household.

Hospital means an institution that: 1) operates as a Hospital pursuant to law for the care, treatment, and providing of in-patient services for sick or injured persons; 2) provides 24-hour nursing service by Registered Nurses on duty or call; 3) has a staff of one or more licensed Doctors available at all times; 4) provides organized facilities for diagnosis, treatment and surgery , either: (i) on its premises; or (ii) in facilities available to it, on a pre-arranged basis; 5) is not primarily a nursing care facility, rest home, convalescent home, or similar establishment, or any separate ward, wing or section of a Hospital used as such; and 6) is not a place solely for drug addicts, alcoholics, or the aged or any separate ward of the Hospital.

Immediate Family Member means a person who is related to the Covered Person in any of following ways: spouse; parent (includes stepparent); child age 18 or older (includes legally adopted and step child); brother or sister (includes stepbrother or stepsister); parent-in-Iaw; son- or daughter-in-Iaw; and brother- or sister-in-Iaw.

Injury means accidental bodily harm sustained by a Covered Person that results directly and independently from all other causes from a Covered Accident. The Injury must be caused solely through external, violent and accidental means. All injuries sustained by one person in anyone Accident, including all related conditions and recurrent symptoms of these injuries, are considered a single Injury.

Insured means a person in a Class of Eligible Persons who enrolls for coverage and for whom the required premium is paid making insurance in effect for that person. An Insured is not a Dependent covered under the Policy.

Pre-existing Conditions means an illness, disease or other condition of the Covered Person, that in the 12 month period before the Covered Person's coverage became effective under the Policy: 1) first manifested itself, worsened, became acute or exhibited symptoms that would have caused a person to seek diagnosis, care or treatment; or 2) required taking prescribed drugs or medicines, unless the condition for which the prescribed drug or medicine is taken remains controlled without any change in the required prescription; or 3) was treated by a Doctor or treatment had been recommended by a Doctor.

Sickness means an illness, disease or condition of the Covered Person that causes a loss for which a Covered Person incurs medical expenses while covered under the Policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness.

Usual and Customary Charge means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided.

10. Exclusions

We will not pay benefits for any loss or Injury that is caused by, or results from:

1. Intentionally self-inflicted Injury.
2. Suicide or attempted suicide.
3. War or any act of war, whether declared or not.
4. Piloting or serving as a crewmember or riding in any aircraft except as a fare-paying passenger on a regularly scheduled or charter airline.
5. Commission of, or attempt to commit, a felony, an assault or other illegal activity.
6. Commission of or active participation in a riot, or insurrection.
7. Flight in, boarding or alighting from an aircraft or any craft designed to fly above the Earth's surface, except as: (A) A fare-paying passenger on a regularly scheduled commercial or charter airline; (B) A passenger in a non-scheduled, private aircraft used for pleasure purposes with no commercial intent during the flight; (C) A passenger in a military aircraft flown by the Air Mobility Command or its foreign equivalent.
8. Travel in or on any on-road and off-road motorized vehicle not requiring licensing as a motor vehicle.
9. An accident if the Covered Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator's license, except while participating in Driver's Education Program.
10. Alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a Doctor.
11. An accident that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, We will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days.
12. An accident that results in a cardiovascular accident or stroke caused solely and exclusively by exertion, as verified by a Doctor, while the Covered Person participates in a Covered Activity.
13. The Covered Person being under the influence of drugs or intoxicants, unless taken under the advice of a Doctor.
14. For specific named hazards: motorcycling, scuba diving, jet, snow or water skiing, mountain climbing (where ropes or guides are used), sky diving, amateur racing, piloting an aircraft, bungee jumping, spelunking, whitewater rafting, surfing, and parasailing.

In addition to the exclusions above, We will not pay Medical Expense Benefits for any loss, treatment or services resulting from or contributed to by:

1. Pre Existing Conditions: However, a Pre Existing Condition will be covered after the person has been continuously insured for 6 months under another Student Health Insurance policy issued to the Policyholder, provided continuous insurance is maintained.
2. Treatment by persons employed or retained by a Policyholder, or by any Immediate Family Member or member of the Covered Person's household.
3. Treatment of Osgood-Schlatter's Disease, osteochondritis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, detached retina unless caused by an Injury, or mental disorder or psychological or psychiatric care or treatment (except as provided in the Policy), whether or not caused by a Covered Accident or Sickness.
4. Damage to or loss of dentures or bridges, or damage to existing orthodontic equipment.
5. Expense incurred for treatment of temporomandibular or craniomandibular joint dysfunction and associated myofacial pain.
6. Blood, blood plasma, or blood storage, except expenses by a Hospital for processing or administration of blood.
7. Cosmetic surgery, except for reconstructive surgery needed as the result of an Injury or Sickness.
8. Any elective treatment, surgery, health treatment, or examination, including any service, treatment or supplies that: (a) are deemed by Us to be experimental; and (b) are not recognized and generally accepted medical practices in the United States.
9. Eyeglasses, contact lenses, hearing aids, wheelchairs, braces, appliances, examinations or prescriptions for them, or repair or replacement of existing artificial limbs, orthopedic braces, or orthopedic devices, except as provided in the Policy.
10. Expenses payable by any automobile insurance policy without regard to fault. (This exclusion does not apply in any state where prohibited).
11. Treatment or service provided by a private duty nurse.
12. Eye refractions or eye examinations for the purpose of prescribing corrective lenses or for the fitting thereof, unless caused by an Injury incurred while covered under the Policy.
13. Covered medical expenses for which the Covered Person would not be responsible for in the absence of the Policy.
14. Conditions that are not caused by a Covered Accident or Sickness.
15. Participation in any activity or hazard not specifically covered by the Policy.
16. Any treatment, service or supply not specifically covered by the Policy.
17. Any treatment, services or supplies received by the Insured that are incurred or received while he or she is in his or her Home Country.
18. Personal comfort or convenience items. These include but are not limited to: Hospital telephone charges; television rental; or guest meals.
19. Routine nursery care, physicals and dental care and treatment.
20. Birth defects and congenital anomalies; or complications which arise from such conditions.
21. Rest cures or custodial care.
22. Any condition for which the Insured is entitled to benefits under any Workers' Compensation Act or similar law.
23. Organ or tissue transplants and related services.
24. Injury sustained while participating in an amateur, club, intramural, interscholastic, intercollegiate, professional or semi-professional sports.
25. Confinement of institutional care.
26. Services, supplies, or treatment including any period of Hospital confinement which were not recommended, approved and certified as necessary and reasonable by a Doctor; or expenses which are non-medical in nature.
27. Sexually transmitted diseases or immune deficiency disorders and related conditions. This exclusion does not apply to the care or treatments of Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or Human Immunodeficiency Virus (HIV) infection, or any illness or disease arising from these medical conditions.
28. Expenses incurred for services related to the diagnostic treatment of infertility or other problems related to the inability to conceive a child, unless such infertility is a result of a covered Injury or Sickness.
29. Expenses Incurred for birth control including surgical procedures and devices.
30. Nasal or sinus surgery, except surgery made necessary as the result of a covered injury a deviated nasal septum including sub mucous resection and surgical correction thereof
31. Expenses incurred in connection with weak, strained or flat feet, corns, calluses or toenails.
32. Treatment of acne.

This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit the underwriting company from providing insurance, including, but not limited to, the payment of claims.

11. Preferred Provider Organization (PPO)

In network benefits as described herein are based on, and will be limited to, an incurred loss for medical treatment received from a physician or hospital approved through a participating Preferred Provider Organization (PPO). Benefits are 80% - 100% of covered medical expenses shown within the schedule of benefits for medical treatment or service with a deductible of $90 for ISO Med 1 or $100 for ISO Med 2. If you receive treatment from a non-participating physician or hospital, your benefits will be reduced to 70% of Usual & Customary of covered medical expenses shown within the schedule of benefits for medical treatment or service with a deductible of $225 for ISO Med 1 or $250 for ISO Med 2.

Beech Street Preferred Provider Network

Persons insured under this plan may choose to be treated within or outside of the Beech Street Network. The Beech Street Network consists of hospitals, doctors and other health care providers organized into a network for the purpose of delivering quality health care at affordable rates. Reimbursement rates will vary according to the source of care as described under the Summary Schedule of Benefits herein.

In order to use the services of a Network provider, you must present an Identification card that is given to all covered individuals in this insurance plan. Utilization of a network provider does not guarantee eligibility or right to Injury and Sickness benefits under this plan. Providers may be periodically added or deleted as participants in the Beech Street Network. Not all doctors practicing at a hospital elect to participate in the Beech Street Network. Insured's are responsible to verify that a provider is a participant prior to services being rendered.

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.

12. Assistance services

In addition to the insurance protection provided by these plans, ACE USA has arranged with Europ Assistance Services, Inc. to provide you with access to its travel assistance services. These services include:

• Medical Assistance including referral to a doctor or medical specialist, medical monitoring when you are hospitalized, emergency medical evacuation to an adequate facility, medically necessary repatriation and return of mortal remains.
• Personal Assistance including pre-trip medical referral information and while you are on a trip: emergency medication, embassy and consular information, lost document assistance, emergency message transmission, emergency cash advance, emergency referral to a lawyer, translator or interpreter access, medical benefits verification and medical claims assistance.
• Travel Assistance including emergency travel arrangements, arrangements for the return of your traveling companion or dependents and vehicle return.

If in the U.S. or Canada call (800) 243-6124. Otherwise call collect (202) 659-7803.

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. If the Student Health Service is not available, contact Beech Street PPO Network for a participating doctor at (800) 432-1776 or www.beechstreet.com.

Present your insurance ID card to the PPO Provider and follow their instructions.

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.

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.

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. How to enroll by fax or mail

1. Complete the application form. Answer all questions to avoid delays.
2. Specify the required months of coverage - Minimum 3 month / Maximum 19 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.

15. Underwriter

Underwritten by ACE American Insurance Company, Philadelphia, Pennsylvania.

This brochure provides a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the Policy issued to: Trustee of ACE USA Accident and Health Insurance Trust in Washington, D.C. The Policy is subject to the laws of the state in which it was issued. Coverage may not be available in all states or certain terms or conditions may be different if required by state law. Please keep this information as a reference. Under HIPPA Privacy Rule, we are required to provide you with notice of our legal duties and privacy protection with respect to personal health information. You should receive a copy of this notice with the enrollment materials. If, at any time, you wish to request a copy of ACE USA’s HIPPA Privacy Notice, write ACE USA Accident & Health Compliance Office, Two Liberty Place, 436 Walnut Street, Philadelphia, PA 19106 or call (215) 640-2611.

16. Refund of premium

Unearned funds will be refunded, less a $50 processing fee, for the number of full months only. Premium refunds, less a processing fee, will be considered only for entry into the armed forces or if you are not eligible for this insurance under to 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.