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| SENTRY STUDENT SECURITY PLAN | Oregon (2005-2006) |
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ELIGIBILITY Any full or part time Student who is registered and attending a college or university is eligible to enroll. International Students are eligible for Plan II only. Your spouse and your dependent Children up to age 25 (who rely on the Student for support and maintenance and reside in the United States) are also eligible, if you enroll. The limiting age does not apply to mentally or physically handicapped Children. The attendance requirement will be waived for a four month period if immediately following a covered four month period, provided the Student remains registered at a college or university in the United States. This means that you may maintain your coverage during the summer or any other four month absence. You may also maintain your coverage for eight months after graduation, if you and your Dependents remain in the United States. This coverage is not available for California residents who are Medicare eligible. INSURED'S EFFECTIVE DATE Your coverage becomes effective on a. The Effective Date you selected on the Enrollment Form; or b. The date your completed Enrollment Form and the correct premium (U.S. funds) are received by the Plan Administrator — whichever is later. Coverage for a newborn Child of an Insured will become effective from birth if correct pro-rata premium is received by the Plan Administrator within 31 days from the date of birth. TERMINATION DATE
Coverage will terminate on the earliest of the following dates: BASIC PLAN BENEFITS When, as the result of an Accident or a Sickness, the Insured incurs Loss while insured under the Policy, the Company will pay benefits for the following medical services up to the Basic Plan Maximum Benefit, subject to the limits for the specific medical services listed below, for each Accident or each Sickness, unless specified otherwise. No benefits are payable for charges incurred before insurance begins or after insurance ends, except as provided in the Extended Benefits provision. A charge will be considered incurred on the date the service is performed. The amount payable for Covered Charges will be determined by the Basic Plan Benefits in effect at the time each charge is incurred. Covered Charges will not exceed the Reasonable and Customary charges for the services and supplies listed.
MAJOR MEDICAL PLAN BENEFITS When the total Basic Plan Maximum Benefit of $3,000 for Plan I or $5,000 for Plan II has been paid by Sentry as a result of a Loss incurred by an Insured for an Accident or a Sickness, Sentry will pay 80% of the Covered Charges, not to exceed the Reasonable and Customary charges, for the Accident or Sickness covered under the Basic Plan Benefits which exceed the Basic Plan Maximum Benefit, up to the Major Medical Plan Maximum Benefit for each Accident or each Sickness. No benefits are payable for charges incurred before insurance begins or after insurance ends, except as provided in the Extended Benefits provision. A charge will be considered incurred on the date the service is performed. The amount payable for Covered Charges will be determined by the Major Medical Plan Maximum Benefit in effect at the time each charge is incurred.
*If an Insured is involved in an Accident, which results in injuries or death, We will pay for the losses as described in the Master Policy for each Accident. Note: Your benefits may be limited as mandated by your state. Please see the Master Policy or your evidence of insurance coverage for details.
PREMIUM No premium refunds are payable except when an Insured enters the Armed Forces at which time a pro-rata refund will be made upon request. If a check is returned by a bank for insufficient funds, improper endorsement, account closed, etc., coverage will be rescinded and the Student must pay an additional service charge of $15 and submit a money order or a certified check, for the premium. It is the Student's responsibility to make payments on the due dates, whether or not a billing statement is received.
MONTHLY PREMIUM RATES
DEFINITIONS Please see the Master Policy or your evidence of insurance coverage for individual state details. Accident - Bodily injury, directly caused by specific accidental contact with another body or object that is unrelated to any Pre-Existing Condition and causes Loss beginning while insured under the Policy. Consultant Doctor Services - A one on one consultation with a Doctor for the purpose of obtaining a second opinion regarding the Insured's Accident or Sickness. The Insured must be referred to the Consultant Doctor by their primary Doctor. Consultant Doctor Services does not include Doctor's services for interpretation of diagnostic testing. Elective Surgery and Elective Treatment - Surgery or medical treatment which is not necessitated by a pathological change occurring after the Insured's Effective Date of Coverage. Elective surgery includes, but is not limited to: tubal ligation; vasectomy; breast reduction; cosmetic surgery; sexual reassignment surgery; and submucous resection and/or other surgical correction for deviated nasal septum, other than for necessary treatment of covered acute purulent sinusitis. Elective treatment includes, but is not limited to: treatment for acne; weight reduction; infertility; learning disabilities; and routine physical examinations. Pre-Existing Conditions - Any Accident or Sickness which originated, was diagnosed, treated or recommended for treatment before the Effective Date of Coverage under the Policy. Generally, pre-existing condition exclusions do apply, however see your individual state policy for specific state details. California residents – Pre-Existing Conditions during the fist six months of coverage under the Policy, unless insured under a prior health plan that terminated within the 62 days before coverage under the Policy began, then credit will be given for the time an Insured was covered under that prior policy. Sickness - Illness, disease, pregnancy, or Mental Disorder which: (1) is first contracted or conceived while covered under the Policy; (2) is unrelated to any Pre-Existing Condition; and which (3) causes Loss beginning while covered under the Policy. Sickness includes trauma-related disorders due to injuries sustained while insured which otherwise do not meet the definition of Accident. LIMITATIONS Please see the Master Policy or your evidence of insurance coverage for individual state details.
1. Sentry will pay 80% of the Covered Charges, not to exceed the Reasonable and Customary charges, for surgical procedures. Benefits will not exceed the plan benefit limits. Surgical benefits include all
Doctor charges before and after surgery. Doctor nonsurgical treatment benefits are not payable for pre- or
post-operative care. Consultant Doctor Services are paid in addition to surgical benefits. Please see the Master Policy or your evidence of insurance coverage for individual state details. This insurance does not cover: 1) services provided by: (a) any College or
University Student Health Service; or (b) by any person employed or retained by such school;
(Available only if Plan II is purchased) The policy maximum (Plan II) can be increased to $100,000 for an additional premium. All Accident and Sickness insured family members must enroll.
MONTHLY PREMIUM
Multiply the rates shown above by 4 to determine the tri-annual premium. Catastrophic Coverage is optional and available to Plan II Accident and Sickness Insureds. All Accident and Sickness insured family members must enroll. The Optional Catastrophic Coverage is presently not available to Students attending schools in Pennsylvania.
Only available with selection of Sentry Student Security Plan II (Additional Premium Required- See Rate Chart) DENTAL BENEFITS BENEFITS If an Insured incurs charges for Dental Services while the Policy is in effect and the Insured is covered under the Dental Benefit, Sentry will pay the percentage shown in the Dental Services section and which: a. Do not exceed the Reasonable and Customary charges for the Dental Services; and b. Do not exceed the policy year maximum per Insured of $1,000; and c. Are in excess of the policy year deductible per Insured of $50. DENTAL SERVICES Class I Services (80% of Covered Charges)
b. Topical application of fluoride for Insureds under age 14; c. Sealants for Insureds under age 14; d. Emergency oral examination for pain relief.
a. Acrylic, amalgam, plastic, porcelain, silicate or stainless steel restorations; b. Oral surgery including extractions; c. Endodontics; d. Periodontics; e. Individual crowns; f. Bridges; g. Initial dentures; h. Space maintainers.
Only Available with Purchase of Plan II Sentry Student Security Plan
DENTAL LIMITATIONS Benefits for Dental Services are limited as follows: ELECTIVE LIMITATION If an Insured elects a more expensive procedure than is usually given, benefits will be limited to the cost based on a standard procedure. DENTAL EXCLUSIONS No benefit will be paid for charges incurred:
2) for any service performed for cosmetic reasons. This exclusion will not apply to procedures performed as a result of congenital defects of a newborn Child; 3) charges for which an Insured has benefits provided under any Workers’ Compensation or Occupational Disease Law; 4) for general anesthesia except when administered for a covered Oral Surgery procedure performed by a dentist; 5) for oral hygiene instructions and dietary instructions; 6) for plaque control programs; 7) for charges for hospital services; 8) for Myofunctional Therapy; 9) for treatment of temporomandibular joint dysfunction (TMJ); 10) for hypnosis; 11) for any operation or service not performed by a Doctor or dentist; 12) for surgery required to restore occlusion; 13) for dentures which have been lost, mislaid, or stolen; 14) for orthodontics or interceptive orthodontia; 15) for dental implants; 16) for inlays, onlays or gold fillings; 17) for replacement prosthodontic appliances, cast restorations, individual crowns and jackets; 18) for prescription drugs.
ENROLLMENT INSTRUCTIONS (U.S. Funds Only) 899 Skokie Boulevard Northbrook, Illinois 60062-4029
POLICIES AND IDENTIFICATION CARDS You will receive an evidence of insurance coverage which includes all policy provisions, an identification card and a claim form. VERIFICATION OF COVERAGE Coverage may be verified by either calling the Plan Administrator or the Insurance Company. CLAIMS In the event of a claim, use the claim form included with your evidence of insurance coverage, or you can obtain a claim form from your College or University Student Health Service, or by contacting:
Policy Benefits, P.O. Box 8025 Stevens Point, WI 54481 1-800-426-7234 THIS IS NOT A CONTINUATION OR RENEWAL OF ANY PRIOR POLICY ISSUED TO THE POLICYHOLDER. This brochure is intended as a brief description of coverage. Please refer to Master Policy for details of benefits and provisions, or your evidence of insurance coverage. PLAN ADMINISTRATOR
The Sentry Student Security Plan is administered nationally by:
E.J. Smith Insurance Agency 899 Skokie Boulevard
(847) 564-3660 (In CA: License #OB69159)
The master policy 180-824 is issued to: Situs, Washington, D.C.
UNDERWRITTEN BY:
Stevens Point, WI
This plan is available to students attending schools in and On-Line students
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