12. Loss resulting from being legally intoxicated or under

CONFORMITY WITH STATE STATUTES
Any provision of this plan of insurance 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.
EXCLUSIONS AND LIMITATIONS
1. Treatment, services or supplies which:
· Are not Medically Necessary;
· Are not prescribed by a Doctor as necessary to
treat an Injury;
· Are determined to be Experimental/Investigational
in nature;
· Are received without charge or legal obligation to
pay;
· Are received from persons employed or retained
by the Policyholder or any Family Member, unless
otherwise specified; or
· Are not specifically listed as Covered Charges in
this Policy.
2. Intentionally self-inflicted Injury, violating or attempting
to violate any duly enacted law. Injury by acts of war,
whether declared or not. War means an interruption of
all relations between nations and an authorized contestation of armed forces by the constitutional authority
of the nations. War does not include acts of terrorism.
3. Injury received while traveling or flying by air, except
as a fare-paying passenger on a regularly scheduled
commercial airline.
4. Services or supplies for the treatment of an Occupational Injury which are paid under the North Carolina
Workers’ Compensation Act only to the extent such
services or supplies are the liability of the employee,
employer or workers’ compensation insurance carrier according to a final adjudication under the North
Carolina Workers’ Compensation Act or an order of
the North Carolina Industrial Commission approving a
settlement agreement under the North Carolina Workers’ Compensation Act.
5. Injury contributed to by the use of alcohol or drugs not
prescribed by a Doctor.
6. Fighting, except as an innocent victim.
7. Heart and/or circulatory malfunction resulting from
participation in a Covered Activity.
8. Repetitive motion Injuries, strains, hernia, tendinitis,
bursitis and heat exhaustion not related to a specific
Injury.
9. Dental treatment, except as specifically stated.
10.Eyeglasses, contact lenses, routine eye exams or
prescriptions therefore.
11. Injury sustained while committing or attempting to
commit a felony.
12.Loss resulting from being legally intoxicated or under
the influence of alcohol as defined by the laws of the
state in which the Injury occurs.
13.Suicide or attempted suicide while sane or insane.
14.Injury sustained while operating, riding in or upon,
mounting or alighting from, any two- or three- or fourwheeled recreational motor/engine driven vehicle or
snowmobile or all terrain vehicle (ATV).
15.Injury sustained scuba diving, surfing, roller skating,
skateboarding or rodeo.
16.Injury sustained while participating in or practicing for
any professional, intercollegiate or club sports activity,
except as specifically provided.
CLAIM PROCEDURE
The Insured Person should:
1.Obtain a claim form from the Student Wellness Center,
or by contacting the claim administrator, Administrative
Concepts, Inc. (ACI).
2.Complete a claim form and mail it to ACI within 60 days
of the date of the Injury or commencement of the Sick ness, or as soon thereafter as possible. Mail the claim
form to Administrative Concepts, Inc., 994 Old Eagle
School Road, Suite 1005, Wayne, PA 19087-1802.
3. Claim forms are available online at www.visit-aci.com or
by calling 888-293-9229. If the providers have given you
bills, attach them to the claim form.
4. Direct all questions regarding benefits available under
this Plan, claim procedures, status of a submitted
claim or payment of a claim to ACI. Online claim status is
available at www.visit-aci.com or by calling 888-293 9229. Select option “2” for Customer Service.
5. Itemized medical bills must be attached to the claim
form at the time of submission. Subsequent medical bills
received after the initial claim form has been submitted
should be mailed promptly to ACI. No additional claim
forms are needed as long as the Insured Person’s name
and identification number are included on the bill.
6. The physicians and hospitals may submit itemized bills
directly to ACI electronically using Payor # 22384 or
mailing them to ACI.
PREFERRED PROVIDER INFORMATION
By enrolling on the Student Health Insurance Plan you have
access to the My First Health Preferred Provider Network.
Please read the following information so you will know
from whom or what group of provider’s health care may
be obtained.
This enhancement to your program does not require you
to use a Preferred Provider. You may receive care from
any license provider (benefit eligibility is subject to the plan
design and the exclusions and limitations as specified in
the policy), but if you incur any expense using a Preferred
Provider you may lower your out-of-pocket expense.
You may check for My First Health Preferred Providers by
calling 1-800-226-5116 or visiting www.myfirsthealth.com.
APPEALS PROCEDURE
If Your claim is denied You will be notified of the reason
with a description of any additional information necessary
to appeal the denial. If You or Your provider would like additional information or have a complaint concerning the denial, please contact the Insurer’s Third Party Administrator,
Administrative Concepts, Inc. (ACI) at 888-293-9229. ACI
will address concerns and attempt to resolve the complaint.
If ACI is unable to resolve the complaint over the phone,
You may file a written internal appeal by writing to ACI.
Please include Your name, home address, policy number,
and any other information or documentation to support the
appeal. The appeal must be submitted within 60 days of the
event that resulted in the complaint. ACI will acknowledge
Your appeal within 10 working days of receipt or within 72
hours if the appeal involves a life-threatening situation.
A decision will be sent to You within 30 days. If there are
extraordinary circumstances involved, ACI may take up to
an additional 60 days before rendering a decision.
Underwritten By:
Guarantee Trust Life Insurance Company
Glenview, IL
Plan Administered By:
First Agency, Inc.
5071 West H Avenue
Kalamazoo, MI 49009-8501
Ph. (269) 381-6630
www.1stAgency.com
Claims Servicing Address:
Administrative Concepts, Inc.
994 Old Eagle School Rd.
Suite 1005
Wayne, PA 19087-1802
Ph. (888) 293-9229
www.visit-aci.com
Local Servicing Provided By:
HVWM/Bankers Insurance
P.O. Box 20, Asheville, North Carolina 28802
Ph. (828) 253-2371
NOTE
Keep this brochure as a summary of the Insurance. No individual Policies will be sent. If any
discrepancies exist between the brochure and
the Policy, the Policy on file with the College
governs the payment.
STUDENT
ACCIDENT AND
SUPPLEMENTAL SICKNESS
INDEMNITY PLAN
Coverage
Effective
8/1/13 - 8/1/14
2013-2014
Policy No. 324-120-012-R
Policy #324-120-012-R
Dear Students, Parents and Guardians:
In an effort to provide the best possible health care to our
students, Belmont Abbey College is making available a
Blanket Accident and Supplemental Sickness Indemnity
Policy for its students. Please take a few minutes to review the following information.
All full-time day-program students attending Belmont Abbey College are automatically enrolled in the Accident
and Supplemental Sickness Indemnity plan. To be exempt from this coverage and fee, you are required to
show proof of other medical insurance. The waiver
form must be completed online at the following link:
http://1stagency.com/forms/waiver_belmontabbey.php
no later than September 21, 2013 (February 14, 2014
for Spring Term enrollees).If the waiver is not received
by those dates, the fee will remain on your bill. The cost
for students entering the Fall Term is $363.00, for the
Spring Term $254.00.
If your personal insurance is an HMO. We urge you
to seriously consider enrolling in the school-sponsored
plan. Many HMO’s will only pay for treatment outside their
network area when it is an emergency and will not pay
for treatment from doctors out of their area without prior
permission, sometimes not even then.
This Plan protects insured students on and off campus, at
home or while traveling. This Plan is primary to any other
insurance the student may carry.
Sincerely,
The Business Office
Belmont Abbey College
ELIGIBILITY
All full-time day-program students enrolled for a minimum
of 12 credit hours are included in this insurance plan and
the premium for coverage is added to your bill unless
proof of comparable coverage is furnished.
Part-time day-program students enrolled for a minimum of
6 credit hours may purchase this insurance plan. Please
contact the business office for payment details.
REFUND PROVISION
The Company retains the right to investigate student status and attendance records to verify that Policy eligibility
requirements have been met. If the Company discovers
that the Policy eligibility requirements have not been met,
the Company’s only obligation is refund of premium. Eligibility requirements must be met each time a premium is
paid to continue coverage.
TERM OF COVERAGE
The Coverage term for the current school year becomes
effective on 8/1/13 (for Spring Term enrollees 1/1/14) at
12:01 a.m. and terminates on 8/1/14 at 12:01 a.m.
Exceptions will be made for the following:
1. Enrolling as a new or transfer student within 31 days of
enrollment at the school.
2. Within 31 days of ineligibility under another plan of
Creditable Coverage and accepted and exhausted
COBRA continuation of coverage if offered.
Coverage terminates at the earliest of:
• the termination of the Policy;
• the last day of the Term of Coverage for which
premium is paid;
• the date the insured ceases to be an eligible person.
Coverage remains in effect during holiday and vacation
periods. Should an Insured Person graduate or withdraw
from the college, the insurance shall remain in effect until
the end of the period for which premium has been paid.
WAIVER DEADLINE
If You have proof of comparable insurance and wish to
waive coverage, the deadline to waive out of this plan is
9/21/13. For students beginning their studies in the spring,
the deadline is 2/14/14.
DEFINITIONS
Accident: A sudden unforeseeable external event which
results in an Injury.
Covered Charge: A service or supply listed in the certificate and which is performed or given for the treatment of
an Injury.
Injury: Bodily injury due to an Accident which, results
directly and independently of disease, bodily infirmity or
any other causes; solely, directly and independently of all
other causes results in medical expense; occurs after the
effective date of coverage under the Certificate; and occurs while the Certificate is in force. All injuries sustained
in any one Accident, including all related conditions and
recurrent symptoms of these Injuries, are considered a
single Injury. Injury includes Complications of Pregnancy
related to an Accident.
Pre-existing Condition: A condition for which medical care, treatment, diagnosis or advice was received or
recommended within the 12 months prior to the Effective
Date of coverage under the Certificate.
Reasonable and Customary Charges, Fees or Expenses: The most common charge for similar professional services, drugs, procedures, devices, supplies or
treatment within the area in which the charge is incurred,
so long as those charges are reasonable.
BASIC ACCIDENT MEDICAL EXPENSE BENEFIT
Treatment of Injury must begin within 30 days of covered accident.
(All amounts are on a per Injury basis, unless otherwise stated)
Maximum Benefit Amount, per Injury
$10,000
Automobile Accident Maximum Benefit Amount
$500
Deductible, per Injury
$0
Insured Percentage
100% of R&C*
Benefit Period
52 weeks
Covered Services
Treatment by a qualified Doctor or surgeon; Hospital and nursing services; Miscellaneous Hospital expense such as
drugs, medicines, x-rays and operating room; Ambulance services; and Dental treatment to sound, natural teeth up to
$200/per tooth.
*R&C = Reasonable & Customary
ADDITIONAL ACCIDENT MEDICAL EXPENSE BENEFIT
Maximum Benefit Amount, per Injury
$5,000
Insured Percentage
80% of R&C*
This benefit applies when a student’s incurred covered charges are more than $10,000. The maximum benefit paid
under the Basic Accident and Additional Accident Medical Expense Benefit will never be more than $15,000.
SUPPLEMENTAL SICKNESS INDEMNITY BENEFIT
Maximum Benefit Amount, per Sickness**
$10,000
Deductible
$0
Covered Charges:
- Outpatient Miscellaneous Hospital Expense, such as, but not limited to
laboratory tests, x-rays, and MRIs.
R&C*
- Outpatient Doctor’s Fees, including surgeon’s fees and anesthesiologist
R&C*
- Outpatient Hospital Emergency Care, including use of ER room and supplies
and Imaging procedures and laboratory tests performed while patient is an
emergency room patient
R&C*
**Sickness means illness or disease; routine and preventive services are not covered under this benefit.
*R&C = Reasonable & Customary
OTHER BENEFITS
Medical Evacuation
Up to $10,000
Repatriation
Up to $7,500
This is a summary of coverage. It does not contain all provisions, limitations and exclusions.
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