Deluxe Plan 2008-2009

TEL: 1.888.533.7654

International Student Plan - Deluxe
(Policy Number - GLB9124046)

ELIGIBILITY

International Students with F-1 visas under the age of 65 enrolled in a full time Associate, Bachelor, Master or Ph.D. degree program, or formal ESL program at a university, who are currently registered with no less than 6 credits hours (unless such school's full-time status requires less credited hours) *, and International Visiting Scholars with J-1 visas under the age of 65, are eligible and qualified to enroll. Students and Scholars may also purchase dependent coverage. Eligible and qualified dependents are the spouse and unmarried children under 19 years of age who are not self supporting. Dependent eligibility expires concurrently with that of the Insured Student/Scholar.

*The six credit hours requirement is waived for summer, if the applicant will continue to register as a full time student in the following fall term.

EFFECTIVE DATE OF COVERAGE

Coverage for an Insured Individual (except for whom the Continuous Coverage provision described herein applies), who makes a premium payment in accordance with the Enrollment provisions stated herein, shall become effective on the latter of:

The Effective Time and Date of the Policy as set forth in the Policy Schedule; or
The day after the date the premium is received by the Policyholder, Company Agent, or Administrator, when premium payment is made within the Enrollment Period as related to any semester beginning date (Annual, Fall, Spring, etc,) shown in the Coverage Schedule; or
The first day following the end of the Waiting Period as set forth in the Policy Schedule when premium payment is accepted by the Company subsequent to any Enrollment Period identified on the Policy Schedule (not applicable to an Insured Student's newly acquired spouse, newborn, or adopted dependent when enrollment occurs within 31 days of attaining such status).

The effective date of coverage for dependents will not precede, nor exceed that of the Insured Student/Scholar.

Coverage will always become effective at the Time specified on the Policy Schedule and on the date determined within this provision. In no event may a person be insured for a period of more than 12 months. The plan is renewed annually

TERMINATION DATE OF COVERAGE

Coverage for an Insured Student/Scholar shall terminate on the earliest of :

1) The last day of the period for which premium has been paid; or
2) The time and Date this policy terminates as set forth in the Policy Schedule.
3) One month after the date the Insured is no longer eligible, such as registering for less than 6 credit hours, or graduation. *

*A student who has been continuously insured with the Company for 3 months or more, has the option to purchase coverage after graduation for a period of three (3) months.

Coverage under this policy with respect to any dependent shall terminate on the earliest of :

1) The last day of the period for which premium has been paid; or
2) The time and Date this policy terminates as set forth in the Policy Schedule.
3) The time and Date the Insured Student's insurance terminates.

PREMIUM

These rates are valid for coverage which has an effective date on or after August 1, 2009 and until August 1, 2010. Any rate change after these dates will be made public.

Policy Number : GLB9124046

Student/Scholar	Annual Rate	Six (6) Months	Three (3) Months	One (1) Month
Under Age 30	$906	$453	$227	$76
Age 30 & Older	$1577	$789	$395	$132
Spouse	$3750	$1875	$938	$313
Child	$1324	$662	$331	$111

Spouse and minor children may only be enrolled on the date the student/scholar is enrolled or within one month of birth, adoption, marriage or arrival in the U.S.A., and they may only be enrolled if the student/scholar is enrolled.

MEDICAL EXPENSE BENEFITS SCHEDULE

This Policy provides worldwide coverage, except for treatment received in the Insured's home country. When an Insured receives medical treatment by a licensed physician, because of sickness or accidental bodily injury incurred while insured hereunder, the Company will pay the incurred usual, reasonable and medically necessary expenses up to an aggregate lifetime maximum of $500,000 for each sickness or injury, subject to the limitations below.

Sickness or conditions of any kind resulting in the payment of benefits, including maternity, are paid under the policy benefits where the condition or sickness first manifested itself.

Benefits Provided by In Network Providers :

Subjected to the limitations stated below all claims will be paid at 80% of the negotiated fee to a maximum of $25,000. When eligible expenses exceed $25,000, claims will be paid 100% of the negotiated fee. Physician visits will be subject to a $10 co-pay.

Benefits Provided by Out of Network Providers :

All claims will be subject to a $100 deductible and benefits as listed below will be paid at 70% of the Usual and Reasonable expenses incurred up to the maximum benefit.

(Please refer to PREFERRED PROVIDER ORGANIZATION section for details).

SCHEDULE OF COVERED MEDICAL EXPENSES

INPATIENT BENEFITS

ROOM & Board Services

Average semi-private room rate.

Intensive Care

(including 24 hours nursing care.) Not payable in addition to Room&Board charges for services incurred on the same date.

Usual & Reasonable Charges

Hospital Miscellaneous Expenses

for services and supplies such as :

1) the cost of the operating room;
2) laboratory tests;
3) X-ray examinations;
4) anesthesia;
5) drugs or medicines (excluding take home drugs);
6) therapeutic services;
7) pre-admission testing; and miscellaneous supplies.

Usual & Reasonable Charges

Surgery

Physician's fees for a surgical procedure will be paid in accordance with the Medical Data Research Schedule.

Physiotherapy

when prescribed by the attending physician

Usual & Reasonable Charges

Anesthetist Services

in conjunction with the surgery

Usual & Reasonable Charges

Registered Graduate Nurse,

when prescribed by the attending physician

Usual & Reasonable Charges

Physician Visits

$10 co-pay per visit. One visit per day.

Psychotherapy

Psychotherapy, the treatment of mental disorders, nervous disorders, alcoholism, and drug addiction, 100% of the benefit for the first 10 days; 100% of the benefit for the 11 to 30 days if approved; 50% of the benefit if not approved, up to a maximum of 30 days for per policy year.

OUTPATIENT BENEFITS

Surgery

Physician fees for a surgical procedure will be paid in accordance with the Medical Data Research Schedule..

Day Surgery Miscellaneous

when surgery is performed in a hospital emergency room, trauma center, physician's office, outpatient surgical center or clinic, for services and supplies such as :

a) operating room;
b) laboratory tests;
c) X-ray examinations;
d) anesthesia;
e) drugs or medicines; and
f) therapeutic services (excluding physiotherapy);

Usual & Reasonable Charges

Anesthetist Services

in conjunction with the surgery

Usual & Reasonable Charges

Physician Visits

One visit per day $10 co-pay per visit.

Medical Emergency Condition
Diagnostic X-Ray
Lab Procedures
Miscellaneous Tests and Procedures

Usual & Reasonable Charges

Physiotherapy

limit to one visit per day, $45 per visit, 3 visits per week, up to a maximum of $1000 per accident or sickness.

Prescription Drugs

80% of the Usual & Reasonable charges to a maximum of $1,200 per person per policy year.

Psychotherapy

80% of the Usual & Reasonable charges to a maximum of $1,100 per person per policy year.

Other Diagnostic Services and Procedures

MRI's, CAT scans, Ultrasound, Amniocentesis, AFP Screening and Fetal Stress/Non Stress tests or similar procedure, when prescribed by the attending physician up to a combined maximum of $1000. (All charges combined)

OTHER BENEFITS

Ambulance Service for transportation to or from a hospital is paid at Usual & Reasonable Charges.

Braces and Appliances When requested and approved by the attending physician is paid at Usual & Reasonable Charges.

Consultant Physician Services When requested and approved by the attending physician is paid at Usual & Reasonable Charges.

Dental Treatment performed by a physician for treatment of injury to sound natural teeth, $250 per tooth to a maximum of $750 (accident only).

Therapeutic termination of pregnancy To a maximum of $500.

Motor Vehicle Accidents Covered as other injury to a maximum of $50,000.

Pre-existing conditions The benefits will be paid to a maximum of $3,000 per policy year.

Organ Transplants Bone marrow transplants skin grafts, kidney dialysis, or similar treatment all charges combined to a maximum of $10,000 all charges combined.

ACCIDENTAL DEATH AND DISMEMBERMENT

For accidental death or dismemberment occurring within 180 days of the date of accident, the plan will pay, in addition to the medical benefits provided herein, one of the following :

Accidental Loss of :
Accidental Death	$10,000
Both Hands, Feet or Eyes	$10,000
One Hand and One Foot	$10,000
Hand or Foot and One Eye	$10,000
Either Hand or Foot	$5,000
Sight of One Eye	$5,000

Only one of the amounts shown above, the largest, will be paid for loss resulting from any one accident, and shall be in addition to any other indemnity payable for such accident. Loss shall mean in regard to Hand or Hands or Foot or Feet, actual severance through or above the wrist or wrists or ankle or ankles, and loss of sight of eye or eyes shall mean the irrecoverable loss of the entire sight thereof.

REPATRIATION EXPENSE
MEDICAL EVACUATION
If the insured prior to his/her termination date of coverage under the policy, has been hospital confined for a minimum of five (5) consecutive days and can no longer continue as a registered student, benefits will be paid up to a maximum of $25,000 for transportation to the Insured's home country, upon recommendation by the attending physician and prior approval by the Company. For approval, please call AIG Assist at 1-800-626-2427.
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. This benefit does not include the transportation expense of anyone accompanying the deceased.
NON-DUPLICATION OF INSURANCE WITH OTHER INSURERS
When total covered expenses exceed $100.00, the Company will pay all covered expenses up to the limits of the policy that are not paid or payable by other insurance.
DEFINITIONS
INJURY means accidental bodily injury which is the sole cause of the loss and is sustained while the Policy is in force as to the Insured Person whose injury is the basis of the claim. SICKNESS means illness or disease resulting in loss covered by the Policy which is the sole cause of the loss and first manifests itself while the Policy is in force as to the Insured Person whose sickness is the basis of the claim.

PRE -EXISTING CONDITION WAIVER*
PPO (Preferred Provider Organization)
Benefits as described herein are based upon 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 will be reduced to 70% of covered medical expenses shown within the Benefits Schedule for medical treatment or services received from a non-participating physician or hospital, and a $100 deductible will apply. For referral to a participating physician or hospital, please contact NHBC for a referral to a participating doctor: 888-621-7900 PIN # AMA411, or access via the Internet http://providers.nhbc.com (enter AMA411 as your access code and click "Go to Directories" button ). If treatment is received where a PPO provider is not available within 35 miles of the Insured's residence, or in case of emergency, benefits will not be reduced. EMERGENCY CONDITION means an accidental injury or sudden onset of a medical condition which first manifests itself while the insured is covered under the policy. Such a condition is evidenced by the sudden appearance of acute symptoms of severity which would cause a reasonable person to expect a serious impairment or dysfunction of a bodily part or organ.
Coverage for pre-existing conditions, will be provided for medical treatment of an accidental bodily injury or sickness for an Insured who has maintained 6 months of continuous and uninterrupted coverage under this insurance program. *Benefits for pre-existing conditions in the states of Pennsylvania, Florida and New York will be provided in compliance with the state regulations. "Pre-existing condition" means an Injury or Sickness which was contracted or first manifested itself or was treated or recommended for treatment by a licensed physician, or for which medication was prescribed, within 6 months prior to the effective date of the Insured Person coverage under this Policy.
COMPANY'S RIGHT OF SUBROGATION
Payments made by the Company which exceed the Covered Medical Expenses (after allowance for Deductible and coinsurance) payable hereunder shall be recoverable by the Company from or among any persons, firms, corporations, or any insurance organization to or for whom such payments were made for any covered Injury or Sickness.

PREMIUM REFUNDS

No refunds are allowed unless the Insured becomes ineligible for coverage. All refund requests must be in writing with documentation. If a claim has been filed (not necessarily paid), no refund will be made. All approved refunds will be made on a pro-rata basis rounded to the month, less a processing fee.

EXCLUSIONS

Unless otherwise provided within the Schedule of Benefits, the Policy does not cover any loss caused by or contributed to by, nor is any premium charged for :

Any expenses for services rendered by any member of an Insured's family or by employees or physicians or other persons employed or retained by the Policyholder or for the use of the Policyholder's facilities except those benefits specifically listed in the Policy Schedule for Benefits as payable at the Policyholder's Health Service, Infirmary or Hospital; or for ANY EXPENSES FOR SERVICES RENDERED ELSEWHERE WHICH ARE AVAILABLE AT THE POLICYHOLDER HEALTH SERVICE, INFIRMARY OR HOSPITAL EXCEPT IN CASES OF EMERGENCY NATURE; or
Treatment where no accidental bodily injury or sickness is involved; congenital conditions (does not apply to "Newborn" children when benefits are provided as a dependent); pre-existing conditions; elective surgery or treatment (to include but not limited to breast or weight reduction), except cosmetic surgery made necessary by accidental bodily injury occurring while the Insured's coverage is in force (does not apply to "Newborn" children when benefits are provided as a dependent); or
Preventive medicines, serums or vaccines, shots or injections (unless required as a result of accidental bodily injury and administered within 24 hours); drugs (unless dispensed while hospital confined or dispensed when Out-patient surgery is performed and taken in the dosage and for the purpose prescribed by the Insured's physician); or
Treatment or removal of non-malignant moles, warts or boils, acne, actinic or seborrheic keratosis, dermatofibrosis, or nevus of any description or form; halux valgus repair; hernia of any kind; varicosity; sleep disorders, including the testing thereof; deviated nasal septum, except when the direct result of an accidental bodily injury incurred while insured hereunder; TMJ (temporomandibular joint dysfunction) or CMJ (craniomandibular disorder) except when the direct result of accidental bodily injury incurred while insured hereunder or a sickness first manifesting itself while insured hereunder; or
Routine physical examinations; any manner or type of diagnostic testing or evaluation, X-ray or laboratory testing or evaluation (to include routine hospital admission procedures when a general anesthetic is not required) which does not result with or is not directly related to the medical diagnosis and treatment of the accidental bodily injury or sickness for which claim is made hereunder; allergy testing or treatment (does not apply to "Newborn" children when benefits are provided as a dependent); diagnostic testing, evaluation or treatment in connection with infertility or birth control; or
The expense of crutches; wheelchairs; or braces and appliances except when directly applied to the area of injury during the initial treatment and when medically necessary for healing purposes; hearing aids, eyeglasses, contact lenses, eye or hearing testing, examinations or prescriptions thereof; or
The consumption of alcohol; the use of any agent classified as hallucinogenic, psychedelic, or having similar classifications or effects; venereal disease; or having similar classifications or effects; venereal disease; or
Mental Disorder; nervous or neurological disease or disorder, except as provided; or
Suicide or attempt thereat; intentional self-inflicted injuries; or
Violating or attempting to violate, any existing city, state or federal law; or
Committing or attempting to commit a felony; fighting or brawling, except in self-defense; participating in a riot, civil disturbance or political insurrection; or
Pregnancy or childbirth (except when conception occurs while insured hereunder); elective abortion except as provided; elective caesarean section; pregnancy or childbirth for a dependent child of an Insured Student (except for complications arising therefrom); or
Dental treatment or dental X-rays except as specifically provided and then only when injury occurs to sound, natural teeth (does not apply to "Newborn" children when benefits are provided as a dependent); or
Private air travel, including ballooning; ultra-light aircraft, parachuting, parasailing, hang gliding, or bungee jumping; bobsledding, travel in or upon a snowmobile, ATV (All Terrain or similar type vehicle), or any two or three wheeled motor vehicle (incl. motorcycle); participation in scuba diving, skiing, mountain climbing, sky diving, auto racing or any contest of speed; or
Accidental bodily injury or sickness for which the Insured Person is entitled to benefits under any Worker Compensation or Occupational Disease Act or Law; or
War or any act of war or loss suffered by the Insured Person while in the military; naval or air service of any country (any premium paid to the Company for a period not covered by the Policy while the Insured is in such service will be returned pro-rata); or
Acupuncture; or
Treatment received in the Insured's home country.

FILING A CLAIM

In event of Sickness or Injury, the Insured should :

Report to Student Health Service.

If the Student Health Service is not available or further treatment is required, please contact NHBC for a referral to a participating doctor: 888-621-7900 PIN # AMA411, or access via the Internet http://providers.nhbc.com (enter AMA411 as your access code and click "Go to Directories" button ).
Present your insurance ID card to the Participating Provider and follow their instruction.

Complete a Claim Form and attach all itemized bills, statements and receipts and mail to the Claims Department* :

Please send your claim form and all your itemized bills to this address below :
MCA Administrators, Inc. P. O. Box 6540 Harrisburg, PA 17112 1-800-427-9308

Underwriting Company

Insurance Company of the State of Pennsylvania
Member Company of Chartis
Policy Number : GLB9124046

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