Student Accident & Sickness Plan Policy


HOW TO ENROLL

All eligible students will be automatically enrolled in the plan at registration and the premium will be added to their tuition billing.

ELIGIBILITY

All students enrolled for classes at Grambling State University, excluding faculty and staff members, are eligible to enroll in the Plan. Eligible students will automatically be enrolled in the Plan at registration and the premium is included in the "student fees" and assessed during registration. Coverage becomes effective each semester (Fall, Spring, Summer I, and Summer II), Coverage will become invalid for students who leave the school within 31 days of their effective date of coverage. The Servicing Agent should be notified at that time by the student.

The Nurseline is an added benefit for all students at no additional charge. The Nurseline can answer general medical questions, and advise students if they should seek immediate medical attention. The Nurseline is a national hotline and is available toll free at (866) 751-2723. Students can contact the Nurseline Monday-Thursday from 5:00 p.m. 8:00 a.m. and on Friday starting at 11:30 a.m. and to continue for 24 hours throughout the weekend.

LIVE CHAT

In order to server the students using www.gmsouthwest.com we offer LiveChat. LiveChat is an innovative, award winning, customer service program that allows students to chat with a member of our staff. This online option allows students to get answers to their questions quickly. The system records the student's information before they speak to a staff member allowing our staff to have the account open and ready to answer any questions. The student is provided with a transcript of the conversation via email for their records.

EFFECTIVE AND EXPIRATION DATES

Early Arrival Students may begin enrolling as of 06/30/2012 at a daily rate. Coverage becomes effective each semester (Fall, Spring, Summer I and Summer II) at registration and the premium is included in the "student fees" and assessed during registration. Effective date for Fall is 08/12/2012, Spring is 01/06/2013, Summer I is 05/18/2013 and Summer II is 06/23/2013.

CREDIT FOR PRIOR COVERAGE

This plan provides portability of coverage as it relates to "pre-existing" health conditions:

  1. If, at the time of enrollment, you have not been covered by Prior Creditable Coverage, these Policies will not cover pre-existing conditions until you have continuous coverage for twelve months under these Policies.
  2. If you were covered by Prior Creditable Coverage any time within the last twelve months and you enroll in this plan within 63 days of having coverage under the previous plan, credit will be given for each month of creditable coverage toward satisfaction of the twelve month waiting period for pre-existing conditions. To obtain credit for previous coverage, you must provide evidence of Prior Creditable Coverage" within 30 days of enrollment in these Policies.

CONTINUOUS COVERAGE

If an insured person was covered to the Expiration Date of the prior student health insurance policy of the Policyholder, he or she will not be denied benefits under these Policies for an Injury or Sickness which was the basis of a covered claim under the prior policy. The student must be enrolled in these Policies and pay the Premium within 31 days of the expiration date of the prior student health insurance policy. For purposes of this provision, benefits for the aggravation of an old Injury will be paid on the same basis as a Sickness.

PORTABILITY OF COVERAGE

Insured persons who are covered by these Policies until: (a) they are enrolled in another institution; or (b) the Policies Expiration Date, will not experience a break in coverage if the other institution maintains a master policy with Pan-American Life Insurance Company. Enrollment in the other institution's policy and initial premium payment must occur: (a) within 31 days after becoming eligible for coverage; and (b) no more than 45 days after the Policy Expiration Date.

PREFERRED PROVIDER NETWORK

"Preferred Providers" are Physicians, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices. The network provider for this plan is the Verity Health Network. It is to your advantage to use a Preferred Provider in order to maximize your savingsand reduce your out-of-pocket expenses. You may obtain information regarding Preferred Providers by calling 1-800-574-9858 or by visiting www.verityhealth.com.

MEDICAL BENEFITS SCHEDULE

When your covered Injury or Sickness requires treatment by a Physician, these Policies will provide benefits for the Usual and Customary (U&C) Charges (see definition of U&C) incurred as scheduled below, up to a Maximum Benefit for each Injury of $7,000, or each Sickness of $4,000. Students must obtain a referral from the Health Center (during business hours) before receiving treatment outside of the Health Center. This does not apply to students outside the Lincoln Parish area at the time of the emergency or illness. Benefits will not be provided for services which are not listed in the Medical Benefits Schedule.

PART A: BASIC INJURY AND SICKNESS BENEFITS PER ACADEMIC YEAR FOR EACH INJURY AND EACH SICKNESS, SUBJECT TO THE FOLLOWING LIMITS:

*Each Injury and Each Sickness, subject to the following limits: 

COVERED SERVICES Injury Benefit
($7000 Maximum)
Sickness Benefit
($4000 Outpatient Maximum)
    ($6000 Inpatient Maximum)
I.  Inpatient
a. Hospital Room and Board (including Hospital Intensive Care) Semi-private rate Semi-private rate
(Maximum # of days - 35)
b. Hospital Miscellaneous (including the cost of the operating room; laboratory tests; x-rays; anesthesia; drugs - not take home drugs; therapeutic services; supplies; private duty nurse; pathology; radiology; physical therapy) U&C 1st $200 @ 100%, 80% to $6,000 Max.
c. Surgical Treatment U&C $3,000
d. Anesthetist U&C 20% of Surgical Treatment
e. Physician's Non-Surgical Visits (1 visit/day, not paid day of surgery) U&C 1st day $60, thereafter $40
f. Registered Nurse Paid under I.a. Paid under I.a.
II.  Outpatient
a. Hospital Outpatient Surgical Miscellaneous (includes operating room, x-rays and Services and Supplies) U&C $1,000
b. Surgical Treatment U&C $3,000
c. Anesthetist U&C 20% of Surgical Treatment
d. Physician's Non-Surgical Visits (1 visit/day, not paid day of surgery) U&C 1st day $60, thereafter $40
up to 5 visits
e. Physical Therapist (within 30 days following surgery) U&C Paid under II.d.
f. Hospital Emergency Room (when medically necessary) U&C $500 Max with$100 Copay
g. Diagnostic X-rays & Laboratory Services U&C $1,000
III.  Other
a. Ambulance Services (ground service only) U&C $1,000
b. Consultant Physician (when requested by attending Physician) U&C $50
c. Dental Treatment (Injury Only, includes x-rays; does not include biting or chewing injuries) $350/tooth No Benefit
d. Mental and Nervous Disorders Not Applicable Same as any Sickness
e. Maternity Benefits Not Applicable Same as any Sickness
f. Motor Vehicle Injury Same as any Injury Not Applicable
PART B: MEDICAL EVACUATION AND REPATRIATION
Medical Evacuation: following hospital confinement of 5 or more days,
for medical evacuation to the student's home country or a better 
equipped hospital enroute.
Up to $10,000 when pre-approved
     
Repatriation: for preparation and return of a deceased student to 
his/her home country.
Up to $7,500 when pre-approved
PART C: ACCIDENTAL DEATH AND DISMEMBERMENT

Occurring within 180 days from the date of accident, pays in addition one of the following (the largest applicable amount):

Accidental Death/Double Dismemberment $2,500
Single Dismemberment (Arm or Leg) $1,500
Single Dismemberment (Hand, Foot, Eye, or Digit) $1,500
Partial Loss of Digit $  500
PART D: ADDITIONAL BENEFITS

These plans will pay benefits for the items below in accordance with any applicable Louisiana law. Benefits may be subject to deductibles, coinsurance, limitations, and exclusions of these Policies. Description of these Additional Benefits can be found in the Master Policy on file at the University or call the Claim Office. Additional benefits include: Cleft Lip and Cleft Palate Coverage; Pap Test and Mammography Coverage; Transliterator Services Coverage; AD/HD Coverage; Prostate Screening Coverage; Osteoporosis Coverage; Diabetic Care Coverage; Dental Care Hospital Coverage; Clinical Trials Coverage; Severe Mental Illness Coverage; Surgical Center Coverage; Ambulance Coverage; Off-Label Prescription Drug Coverage; and Breast Reconstruction Coverage.

EXCLUSIONS

These Policies does not provide Benefits for expense resulting from:

  1. Air flight, except as a fare-paying passenger on a regularly scheduled flight on a commercial airline.
  2. Dental treatment, except as specifically provided in the Medical Benefits Schedule.
  3. Treatment where no injury or sickness is involved (physical or preventive medicines); or Elective Surgery and Elective Treatment; or abortion. It does not include cosmetic surgery made necessary by Injury.
  4. Expenses resulting from a motor vehicle accident if the Covered Person is not properly licensed to operate the motor vehicle with the jurisdiction in which the accident takes place; (except in Driver's Education Program).
  5. Eyeglasses, contact lenses, and examination for prescribing or fitting them; any other procedure for correction of refractive disorder of the eye or eyes; hearing aids and hearing examinations, except as mandated by state law specifically provided.
  6. Injury or Sickness for which benefits are paid under Workers' Compensation or Occupational Disease Act or Law.
  7. Outpatient Prescription Drugs.
  8. Injury sustained while participating in the practice or play of interscholastic or intercollegiate sports, including the participation in any conditioning program for such sport, contest, or competition.
  9. Intentional self-inflicted Injuries, including drug overdose, unless such Injury results from a medical condition, mental or nervous or substance abuse disorder, or an act of domestic violence; Loss incurred while committing or attempting to commit a felony; or Loss due to voluntary participation in a riot or civil disturbance.
  10. Routine newborn baby care, well baby nursery, and related Physician's charges.
  11. Services provided normally without charge by the Health Center of the Policyholder, or by any person employed or retained by the Policyholder, or services covered or provided by the student health fee.
  12. Treatment of Substance Abuse.
  13. Use of any services or supplies which are experimental, and/ or not in accord with generally accepted standards of medical practice; organ transplants, including donor's expenses.
  14. War or act of war, whether declared or not; and Injury or Sickness resulting from full-time active duty military service.
  15. Pre-existing Conditions not subject to Credit for Prior Coverage, until continuously covered under the University's Accident & Sickness plan for a period of twelve (12) consecutive months.

DEFINITIONS

Elective Surgery and Elective Treatment means surgery or medical treatment which is not necessitated by a pathological change occurring after Your Effective Date of coverage. Elective Surgery includes but is not limited to: tubal ligation; circumcision; vasectomy; breast reduction; sexual reassignment surgery; any services or supplies rendered for the purpose or with the intent of inducing conception; temporomandibular joint dysfunction (TMJ); cosmetic procedures; and submucous resection and/or other surgical correction for deviated nasal septum, other than for treatment of covered acute purulent sinusitis. Elective Treatment includes but is not limited to: allergy testing; treatment for acne; biofeedback-type services; infertility; hypnotherapy; learning disabilities, and weight reduction.

Injury means accidental bodily injury or injuries directly caused by specific accidental contact with another body or object while your coverage is in force. It is unrelated to any pathological, functional, or structural disorder or Injury resulting directly and independently of all other causes, in Loss covered by the Policy. All related injuries and recurrent symptoms of the same or similar condition will be considered one injury.

Medical Emergency means the unexpected onset of an Injury or Sickness that requires immediate or urgent medical attention to avoid death or serious permanent damage to the body, or pain sufficient to warrant immediate care. It does not include elective or routine care.

Pre-Existing Condition means any condition, regardless of the cause of the condition, for which medical advice, prescription medication, diagnosis, care or treatment was recommended or recieved during the 12 months immediately preceding the Effective Date of the Insured's coverage under this Policy. The term does not include genetic information in the absence of a diagnosis of the condition related to such information.

Prior Creditable Coverage means means coverage provided in the United States under any individual or group: health benefits plan, insurance policy or certificate, service contract or HMO contract, or any government health benefit plan.

Sickness means Your bodily sickness, mental sickness, or Maternity which is not a Pre-existing Condition. Sickness includes pregnancy, Complication of Pregnancy and trauma related disorders due to injuries which otherwise do not meet the definition of an Injury. All related sicknesses and recurrent symptoms of the same or similar condition will be considered one Sickness.

Usual and Customary Charges (U&C) means charges for medical services or supplies for which You are legally liable and which do not exceed the average rate charged for the same or similar services or supplies in the geographic region where the services or supplies are received. Usual and Customary Charges are determined by referencing the 50th percentile of the most current survey published by Ingenix for such services or supplies.

CLAIM PROCEDURE

Secure a claim form from the School Office, from the Servicing Agent, or from the GMSW, Inc. website, fill in the necessary information, attach all itemized doctor and hospital bills and send to:

GM-SOUTHWEST, INC.
P.O. Box 6000 • Frisco, TX 75034

Proof of loss must be submitted to the address above within 90 days from the date of Injury or Sickness. To check the status of your filed claim, please call the Claims Office Monday to Thursday 7:30 a.m. to 5:00 p.m. (CST) and Friday 7:30 a.m. to 4:00 p.m. (CST). The telephone number is: 1-800-547-9858. The GM Southwest Inc. website is: www.gmsouthwest.com

FRAUD NOTICE

Any Person who knowingly presents a false or fraudulent claim for payment of loss of benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

 

*For specific costs and further details of the coverage, including exclusions, reductions or limitations, contact the Servicing Agent, log on to your dedicated website at www.gmsouthwest.com or write the Plan Administrator.