| Age Group | ISO Med 1 | ISO Med 2 |
|---|---|---|
| Under 25 | $39 | $29 |
| 25 - 29 | $79 | $69 |
| 30 - 65 | $139 | $119 |
| Spouse | $340 | $258 |
| Each Child | $139 | $94 |
* Minimum term of coverage is 3 months.
| ISO Med 1 | ISO Med 2 | |
|---|---|---|
| Policy Number | UDL4119S | UDL4120S |
Lifetime Medical Maximum |
$500,000 | $200,000 |
Per Injury or Sickness Maximum |
$250,000 | $100,000 |
| Deductible1 per event at Student Health Center2 | $25 | $25 |
| Deductible per event in-network / Out-of-network 1 | $90 / $225 | $100 / $250 |
| Maximum deductible per policy year | $500 | $750 |
Co-insurance in network3 |
80% of first $4,000 100% thereafter | 80% of first $7,500 100% thereafter |
Co-insurance out-of-network3 |
70% of first $4,000 100% thereafter | 70% of first $7,500 100% thereafter |
Medical Evacuation |
$100,000 | $50,000 |
Repatriation |
$50,000 | $25,000 |
| Home Country Coverage | $500 | $500 |
AD&D - Accidental Death
& Dismemberment |
$20,000 | $10,000 |
You are eligible if you are a member of ISO 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:
Your spouse and eligible dependent children 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.
Permanent residents are not eligible for coverage under this Policy.
Coverage will begin at 12:01 am on the latest of the following:
Coverage will terminate on the earliest of the following:
When a covered Injury or Sickness requires treatment by a Physician,
the policy will provide benefits for the Reasonable 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 Reasonable 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.
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.
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.
"Medical Evacuation" means:
All expenses must be authorized in writing or by an authorized electronic or telephonic means in advance.
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 |
|---|---|
| Life | 100% of the Principal Sum |
| Two or more Members | 100% of the Principal Sum |
| One Member | 50% of the Principal Sum |
| Thumb and Index Finger of the Same Hand | 25% of the Principal Sum |
"Member" means Loss of Hand or Foot, Loss of Sight, Loss of Speech, and Loss of Hearing. "Loss of Hand or Foot" means complete Severance through or above the wrist or ankle joint. "Loss of Sight" means the total, permanent Loss of Sight of one eye. "Loss of Speech" means total and permanent loss of audible communication that is irrecoverable by natural, surgical or artificial means. "Loss of Hearing" means total and permanent Loss of Hearing in both ears that is irrecoverable and cannot be corrected by any means. "Loss of a Thumb and Index Finger of the Same Hand" means complete Severance through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the hand). "Severance" means the complete separation and dismemberment of the part from the body.
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.
Covered Expenses means expenses which are for Medically Necessary services, supplies, care, or treatment; due to Illness or Injury; prescribed, performed of ordered by a Physician; Reasonable and Customary charges; incurred while insured under this Policy;
Dependent or Eligible Dependent
means the Insured's Spouse under age 70; or Child who: (a) Is under 26
years of age; and (b) Is not provided coverage as a named subscriber,
insured, enrollee, or coverage person under any other group or
individual health benefits plan, group health plan, church plan, or
health benefits plan, or entitled to benefits under Title XVIII of the
Social Security Act, Public Law 89-97, 42 U.S.C. section 1395 et seq.;
or (c) A Child of any age who is medically certified by a Physician as
having an intellectual disability or a physical disability and is
dependent upon the Insured.
Spouse means the lawful Spouse, under age 70 (unless otherwise stated in the Application), of an Insured.
Child
can include stepchild, foster child, legally adopted child, a child of
adoptive parents pending adoption proceedings, and natural child.
Hospital a Hospital (other than
an institution for the aged, chronically ill or convalescent, resting
or nursing homes) operated pursuant to law for the care and treatment
of sick or Injured persons with organized facilities for diagnosis and
Surgery and having 24-hour nursing service and medical supervision.
Means a place that 1.) is legally operated for the purpose of providing
medical care and treatment to sick or injured persons for which a
charge is made that the Insured is legally obligated to pay in the
absence of insurance 2.) provides such care and treatment in medical,
diagnostic, or surgical facilities on its premises, or those
prearranged for its use; 3.) provides 24-hour nursing service under the
supervision of a Registered Nurse at all times; and 4.) operates under
the supervision of a staff of one or more Doctors. Hospital also means
a place that is accredited as a hospital by the Joint Commission on
Accreditation of Hospitals, American Osteopathic Association, or the
Joint Commission on Accreditation of Heath Care Organizations (JCAHO).
Hospital does not mean:
-a convalescent, nursing, or rest home or facility, or a home for the
aged;
-a place mainly providing custodial, educational, or rehabilitative
care; or
-a facility mainly used for the treatment of drug addicts or alcoholics.
Injury means Accidental bodily Injury or Injuries caused by an Accident. The Injury must be the direct cause of the Loss, independent of disease or bodily infirmity. Any Loss due to Injury must begin after the Effective Date of this Policy.
Insured Person(s) means a person eligible for coverage under the Policy who has applied for coverage and is named on the application and for whom the company has accepted premium. This may be the Primary Insured Person or Dependent(s).
Physician means a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery in accordance with the laws of the jurisdiction where such professional services are performed, however, such definition will exclude chiropractors and physiotherapists.
Pre-existing Condition for the purposes of this Policy means a condition for which manifestation, medical advice, diagnosis, care or treatment was recommended, received or noticed during the 12 months prior to the Effective Date of coverage under this Policy
Reasonable and Customary means the maximum amount that the Company determines is Reasonable and Customary for Covered Expenses the Insured Person receives, up to but not to exceed charges actually billed. The Company’s determination considers: 1) amounts charged by other Service Providers for the same or similar service in the locality were received, considering the nature and severity of the bodily Injury or Illness in connection with which such services and supplies are received; 2) any usual medical circumstances requiring additional time, skill or experience; and 3) other factors the Company determines are relevant, including but not limited to, a resource based relative value scale.
For a Service Provider who has a reimbursement agreement, the Reasonable and Customary charge is equal to the amount that constitutes payment in full under any reimbursement agreement with the Company.
If a Service Provider accepts as full payment an amount less than the negotiated rate under a reimbursement agreement, the lesser amount will be the maximum Reasonable and Customary charge.
The Reasonable and Customary charge is reduced by any penalties for which a Service Provider is responsible as a result of its agreement with the Company.
Sickness means illness or disease contracted and causing loss commencing while the policy is in force as to the Insured Person whose Sickness is the basis of claim. Any complication or any condition arising out of a Sickness for which the Covered Person is being treated or has received Treatment will be considered as part of the original Sickness.
We will not pay benefits for any loss or Injury that is caused by, or results from:
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.
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 PPO 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 PPO networks. Not all doctors practicing at a hospital elect to participate in the PPO networks. Insured's are responsible to verify that a provider is a participant prior to services being rendered.
First Health – to search for participating doctors or hospitals call (800) 226-5116 or www.myfirsthealth.com
Beech Street – to search for participating doctors or hospitals call (800) 432-1776 or www.beechstreet.com
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 First Health or Beech Street Networks. Reimbursement rates will
vary according to the source of care as described under the Summary
Schedule of Benefits and Covered Medical Expenses.
Please mail the completed claim form and accompanying documentation to the claims administrator, Klais & Company, Inc., 1867 West Market Street, Akron, OH 44313. 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 (800) 331-1096 between 9:00 A.M. and 5:00 P.M. EST Monday through Friday or e-mail at iso@klais.com. On line claims status via the internet is available 24 hours a day at www.klais.com
This brochure provides you with the benefits of ISO Med 1 and ISO Med 2 medical insurance plans, as underwritten by United States Fire Insurance Company, by Fairmont Specialty, a part of Crum Forster. The terms of the policies brochure (UDL4119S, UDL4120S) will govern in all cases.
Premium refunds, less a processing fee, will be considered only for entry into the armed forces. Unearned funds will be refunded, less a $50 processing fee, for the number of full months only. 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.
Questions? Please call us at (800)
244-1180 or e-mail to mailbox@isoa.org
ISO Customer Care representatives are standing by to assist you!