| Read Definitions |
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| Distributed by |
MultiNational Underwriters, LLC |
MultiNational Underwriters, LLC |
| Underwriter |
Lloyd's |
Lloyd's |
| Certificate Period Maximum |
$300,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child)
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$250,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child)
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| Maximum Benefit per Injury or Illness |
$300,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child)
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$250,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child)
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| Deductible |
$100 per Injury or Illness
Reduced to $50 if treatment is from Student Health Center
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$100 per Injury or Illness
Reduced to $50 if treatment is from Student Health Center
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| Coinsurance - Claims incurred in US |
For the Certificate Period, Underwriters will pay 80% of the next $5,000 of Eligible Expenses after the Deductible, then 100% to the Certificate Period Maximum
For charges incurred within the PPO or at a Student Health Center, coinsurance will be waived.
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For the Certificate Period, Underwriters will pay 80% of the next $10,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit |
| Coinsurance - Claims incurred oustide of US |
After the Deductible, Underwriters will pay 100% of Eligible Expenses to Certificate Period Maximum |
For the Certificate Period, Underwriters will pay 80% of the next $10,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit |
| Hospital Room & Board |
Average Semi-private room rate, including nursing services |
Average Semi-private room rate, including nursing services |
| Local Ambulance |
Up to $350 per Injury / Illness if Hospitalized as Inpatient |
Up to $350 per Injury / Illness if Hospitalized as Inpatient |
| Intensive Care Unit |
Usual, Reasonable, and Customary charges |
Usual, Reasonable, and Customary charges |
| Hospital Pre-Notification Penalty |
50% of Eligible Medical Expenses |
50% of Eligible Medical Expenses |
| Outpatient Treatment |
Usual, Reasonable, and Customary charges |
Usual, Reasonable, and Customary charges |
| Outpatient Prescription Drugs |
50% of Actual Charge |
50% of Actual Charge |
| Mental Health Disorders |
Outpatient: $50 Maximum per day, $500 Maximum Lifetime
Inpatient: Usual, Reasonable, and Customary charges to $10,000 Maximum Lifetime
Treatment must be not obtained at a Student Health Center
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Outpatient: $50 Maximum per day, $500 Maximum Lifetime
Inpatient: Usual, Reasonable, and Customary charges to $10,000 Maximum Lifetime
Treatment must be not obtained at a Student Health Center
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| Dental Treatment due to Accident |
$250 Maximum per tooth
$500 Maximum per Certificate Period
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$250 Maximum per tooth
$500 Maximum per Certificate Period
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| Dental Treatment to alleviate pain |
$100 Maximum per Certificate Period |
$100 Maximum per Certificate Period |
| Maternity Care for a Covered Pregnancy |
Usual, Reasonable, and Customary Charges |
Usual, Reasonable, and Customary Charges |
| Routine Nursery Care of Newborn |
$750 Maximum per Certificate Period |
$250 Maximum per Certificate Period |
| Therapeutic Termination of Pregnancy |
$500 Maximum per Certificate Period |
$500 Maximum per Certificate Period |
| Physical Therapy & Chiropractic Care |
Maximum $50 per visit per day
Must be ordered in advance by a Physician and not obtained at a Student Health Center
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Maximum $50 per visit per day
Must be ordered in advance by a Physician and not obtained at a Student Health Center
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| Intercollegiate, interscholastic, intramural, or club sports |
$5,000 Maximum per Injury / Illness
Medical Expenses only
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$5,000 Maximum per Injury / Illness
Medical Expenses only
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| Terrorism |
$50,000 Maximum Lifetime Limit, Medical Expenses Only |
$50,000 Maximum Lifetime Limit, Medical Expenses Only |
| Benefit Period for coverage after Policy Termination Date |
60 days from date of Injury or Onset of Illness if Member is Hospitalized on the Termination Date |
60 days from date of Injury or Onset of Illness if Member is Hospitalized on the Termination Date |
| Emergency Medical Evacuation |
$300,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child)
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$250,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child)
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| Emergency Reunion |
$2,500 Lifetime |
$1,000 Lifetime |
| Accidental Death & Dismemberment |
Principal Sum
$25,000 (Participant)
$10,000 (Spouse)
$ 5,000 (Child)
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No coverage |
| Repatriation of Remains |
$25,000 Maximum |
$15,000 Maximum |
| Read Definitions |
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