PLATINUM SELECT- ISO's exclusive comprehensive Accident & Sickness insurance plan for international students

Table of contents

1. Rates
2. Summary schedule of benefits
3. Accident & Sickness benefits
4. Repatriation of remains
5. Medical evacuation
6. Accidental Death & Dismemberment
7. Eligibility
8. Period of coverage.
9. Definitions
10. Exclusions
11. How to enroll by fax or mail
12. Assistance services
13. Claim procedure
14. Underwriter
15. Refund of premium
16. Preferred Provider Organization (PPO)

3. Accident & Sickness Benefits

When a covered Injury or Sickness requires treatment by a Physician, this coverage will provide benefits for the Reasonable and Customary Charges for Medically Necessary Covered Medical Expenses which exceed the Co-Payment per person for each Injury or Sickness. Payment for any Covered Medical Expense will be no more than the Benefit Limit shown for it and will be subject to the co-insurance percentage amount set forth. The total payable for all Covered Medical Expenses will be no more than the Maximum Benefit Limit per Sickness or Injury. Benefits are subject to the Excess Provision.

Covered Medical Expenses include:

1. Due to Injury to an Insured Person provided that treatment by a Physician: a) begins within 30 days after date of Injury; and b) is received within 26 weeks after date of Injury; or
2. Due to Sickness of an Insured Person provided Covered Medical Expenses are incurred within 26 weeks after the date of first treatment for such Sickness.

If a benefit is designated in the Schedule of Benefits, Covered Medical Expenses include:

1. Room and Board Expense: 1) daily semi-private room rate when Hospital Confined; and 2) general nursing care provided and charged for by the Hospital.
2. Intensive Care.
3. Hospital Miscellaneous Expenses: 1) while Hospital Confined; or 2) for pre-admission expenses for being Hospital Confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; x-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies.
4. Physiotherapy. 1 visit per day.
5. Surgery: Physician's fees for inpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this inpatient surgery benefit; or under the outpatient surgery benefit, but not for both.
6. Anesthetist Services: in connection with inpatient surgery.
7. Private Duty Nurse's Services: 1) private duty nursing care only; 2) while Hospital Confined; 3) ordered by a licensed Physician; and 4) a Medical Necessity. General nursing care provided by the Hospital is not covered under this benefit.
8. Physician's Visits: when Hospital Confined. Benefits are limited to one Physician's visit per day. Benefits do not apply when related to surgery. Covered medical expenses will be paid under the inpatient benefit or under the outpatient benefit for Physician's Visits but not both.
9. Pre-admission Testing: limited to routine tests such as: complete blood count; urinalysis; and chest x-ray. If otherwise payable under the Master Certificate, major diagnostic procedures such as: cat-scans; NMR's; and blood chemistries will be paid under the "Hospital Miscellaneous" benefit.
10. Mental and Nervous Disorder (inpatient): benefits are limited to 1 visit per day to a maximum of 30 visits per benefit period.
11. Surgery (outpatient): Physician's fees for outpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this outpatient surgery benefit; or under the inpatient surgery benefit, but not both.
12. Day Surgery Miscellaneous (Outpatient): in connection with outpatient day surgery; excluding non-scheduled surgery and surgery performed in a Hospital emergency room, trauma center, Physician's office, or clinic. Benefits will be paid for services and supplies such as: the cost of the operating room, laboratory tests and x-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies. $5,000 Maximum per Injury or Sickness.
13. Anesthetist (Outpatient): in connection with outpatient surgery.
14. Physician's Visits (Outpatient): Includes injections administered during visit. Benefits do not apply when related to surgery or Physiotherapy. Covered medical expenses will be paid under the outpatient benefit or under the inpatient benefit for Physician's visits but not both.
15. Medical Emergency Expenses (Outpatient): only in connection with a Medical Emergency as defined. Benefits will be paid for the use of the emergency room and supplies.
16. Radiation Therapy (Outpatient)
17. Chemotherapy (Outpatient)
18. Prescription Drugs (Outpatient)
19. Mental and Nervous Disorder (outpatient): benefits are limited to 1 visit per day to a maximum of 40 visits per year.
20. Ambulance Service.
21. Braces and Appliances: 1) when prescribed by a Physician; and 2) a written prescription accompanies the claim when submitted. Replacement braces and appliances are not covered. Braces and appliances include durable, medical equipment which is equipment that: 1) is primarily and customarily used to serve a medical purpose; 2) can withstand repeated use; and 3) generally is not useful to a person in the absence of Injury or Sickness. No benefits will be paid for rental charges in excess of purchase price.
22. Consultant Physician Fees: when requested and approved by the attending Physician.
23. Dental Treatment maximum benefits of $300: 1) performed by a Physician; and 2) made necessary by Injury to Sound, Natural Teeth. Routine dental care and treatment to the gums are not covered.
24. Alcoholism/Drug Abuse Treatment: the benefits and the maximum amounts are specified in the Schedule of Benefits.
25. HIV infection, HIV-related illnesses and AIDS: benefits are limited to a lifetime maximum of $7,500.
26. Benefits are payable only for those Covered Medical Expenses incurred while this coverage is in effect for the Insured Person. No benefits are payable for any expenses incurred after the date insurance terminates, except if an Insured Person is hospitalized on the date his insurance terminates. Benefits will continue to be paid until the completion of the hospital stay, but not to exceed a period of 31 days from the termination date, or the Maximum Policy Benefit, whichever occurs first.
27. Any child born to the Insured on or after the effective date, will be covered for the first 31 days after birth. Coverage for such child will be for Injury or Sickness including medically diagnosed congenital defects, birth abnormalities, prematurity, and nursery care when the child is sick or injured. To continue coverage beyond 31 days, written application and payment of any required premium must be made to ISO and forwarded to the Underwriting Company.
28. Maternity (conception must occur while this coverage is in effect).

Excess Provision: All benefits shall be in excess of all other valid and collectible insurance and shall apply only when such benefits are exhausted. If an Insured's Injury or Sickness is due to an act or omission of another, benefits payable by this plan are subject to recovery from amounts eventually paid to the Insured by or on behalf of, the other person.

Conformity with State Statutes: Any provision of the Master Certificate 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.

4. Repatriation of Remains

If the Insured dies prior to his/her termination of coverage, benefits will be paid up to the maximum stated in the Summary Schedule of Benefits  for: a) cost of embalming; b) coffin; c) transportation of the body to the Insured's home country/country of permanent residence. This benefit does not include the transportation expense of anyone accompanying the deceased.

All expenses must be authorized in writing or by an authorized electronic or telephonic means in advance. For authorization contact On-Call International (866) 509-7715 or (603) 328-1728.

5. Medical evacuation

Benefits will be paid for covered expenses up to the maximum stated in the Summary Schedule of Benefits if any Injury or Sickness commencing during the period of coverage results in the necessary emergency evacuation of the Insured. An emergency evacuation must be ordered by a legally licensed physician who certifies that the severity of the Insured's Injury or Sickness warrants the emergency evacuation.

“Medical Evacuation” means:
1. The Covered Person’s immediate transportation from the place where he or she suffers an Injury or Sickness to the nearest Hospital or other medical facility where appropriate medical treatment can be obtained; or

2. The Covered Person’s transportation to his or her Home Country to obtain further medical treatment in a Hospital or other medical facility or to recover after suffering an Injury or Sickness.

All expenses must be authorized in writing or by an authorized electronic or telephonic means in advance. For authorization contact On-Call International (866) 509-7715 or (603) 328-1728.

6. Accidental Death & Dismemberment

If Injury to the Covered Person results, within 365 days of the date of a Covered Accident, in any one of the losses shown below, We will pay the Benefit Amount shown below for that loss. If multiple losses occur, only one Benefit Amount, the largest, will be paid for all losses due to the same Accident.

Covered Loss & Benefit Amount

Covered Loss	Benefit Amount
Life	100% of the Principal Sum
Two or more Members	100% of the Principal Sum
One Member	50% of the Principal Sum
Thumb and Index Finger of the Same Hand	25% of the Principal Sum

"Member" means Loss of Hand or Foot, Loss of Sight, Loss of Speech, and Loss of Hearing. "Loss of Hand or Foot" means complete Severance through or above the wrist or ankle joint. "Loss of Sight" means the total, permanent Loss of Sight of one eye. "Loss of Speech" means total and permanent loss of audible communication that is irrecoverable by natural, surgical or artificial means. "Loss of Hearing" means total and permanent Loss of Hearing in both ears that is irrecoverable and cannot be corrected by any means. "Loss of a Thumb and Index Finger of the Same Hand" means complete Severance through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the hand). "Severance" means the complete separation and dismemberment of the part from the body.

7. Eligibility

You are eligible if you are a member of ISO, have a current passport or visa and are temporarily residing outside your home country/country of permanent residence while actively engaged in education or research activities. You are 'actively engaged' in education or research activities if you are one of the following:

• F1/J1 valid visa holder. F1 visa holders on OPT are not eligible.
• Undergraduate - registered for and attending classes on full-time basis.
• Scholar or researcher who is invited by an educational organization.
• Student involved in education, educational activities, or research- related activities.

Your spouse and eligible dependent children are also eligible for coverage if accompanying you.

For purposes of this insurance, if the Eligible Person’s home country or country of permanent residence (passport country) is different from the Eligible Person’s country of permanent residence (location in which the Eligible Person permanently resides), the Eligible Person will not be covered in either location. Permanent residents are not eligible for coverage under the Master Certificate.

8. Period of coverage

Coverage will begin at 12:01 am on the latest of the following:

1. The date of departure from your home country/country of permanent residence;
2. The date the application form and premium are received by the Underwriting Company or its designated representative; 
3. The date requested on the enrollment form.

Coverage will terminate on the earliest of the following:

1. The last day for which premium has been paid; 
2. The date the Master Certificate terminates; 
3. The date of entry into active duty military service.

Extension Of Accident and Sickness Insurance Benefits
If a Covered Person is hospital confined at termination of coverage, benefits will continue to be paid until the earlier of either discharge from the hospital they are confined to or until the maximum benefit has been paid, whichever occurs first.  In no event will benefits continue beyond 30 days beyond the term of coverage.

9. Definitions

Eligible Expenses means the Usual, Reasonable and Customary charges for services or supplies which are incurred by the Covered Person for the Medically Necessary treatment of an Injury.  Eligible Expenses must be incurred while this coverage is in force.

Covered Person means a Covered Person [and Dependent] eligible for coverage as identified in the Enrollment/Application for whom proper premium payment has been made when due, and who is therefore a Covered Person under this Master Certificate.

Dependent means a Covered Person’s:
1)    lawful spouse, if not legally separated or divorced.
2)    unmarried Children under age 26.
The age limitations will not apply to a Covered Person’s unmarried Child who is incapable of self-support due to a mental or physical incapacity.  Proof of such incapacity must be furnished to the Company immediately upon enrollment or within 31 days of the Child reaching the age limitation.  Thereafter proof will be required whenever reasonably necessary, but not more often than once a year after the 2-year period following the age limitation.

Spouse means lawful spouse, if not legally separated or divorced.

Child means the Covered Person’s natural Child, adopted Child (or Child placed in the Covered Person’s home for purposes of adoption), foster Child, stepchild, or other Child for whom the Covered Person has legal guardianship (proof will be required).  A Child must reside with the Covered Person in a parent-Child relationship.

Injury means bodily harm which results, directly and independently of disease or bodily infirmity, from an Accident after the effective date of a Covered Person’s coverage under the Master Certificate, while this coverage is in force as to the person whose Injury is the basis of the claim.  All injuries to the same Covered Person sustained in one Accident, including all related conditions and recurring symptoms of the Injuries will be considered one Injury.

Physician means a person who is a qualified practitioner of medicine.   As such, He or She must be acting within the scope of his/her license under the laws in the state in which He or She practices and providing only those medical services which are within the scope of his/her license or certificate.  It does not include a Covered Person, a Covered Person’s Spouse, son, daughter, father, mother, brother or sister or other relative.
 
Pre-Existing Condition means an Injury or Sickness, disease, or other condition during the 12 month period immediately prior to the date the Covered Person’s coverage is effective for which the Covered Person: 1) received or received a recommendation for a test, examination, or medical treatment for a condition which first manifested itself, worsened or became acute or had symptoms which would have prompted a reasonable person to seek diagnosis, care or treatment; or 2) took or received a prescription for drugs or medicine. Item (2) of this definition does not apply to a condition which is treated or controlled solely through the taking of prescription drugs or medicine and remains treated or controlled without any adjustment or change in the required prescription throughout the 12 month period before coverage is effective under the Covered Person’s Plan.

Sickness means Sickness or disease contracted and causing loss commencing while the coverage is in force as to the Covered Person whose Sickness is the basis of claim.  Any complication or any condition arising out of a Sickness for which the Covered Person is being treated or has received Treatment will be considered as part of the original Sickness.

Usual, Reasonable and Customary means 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. The most common charge means the lesser of:
•    The actual amount charged by the provider;
•    The negotiated rate; or
•    The charge which would have been made by the provider (Physician, Hospital, etc) for a comparable service or supply made by other providers in the same Geographic Area, as reasonable determined by Us for the same service or supply.
Geographic Area means the three digit zip code in which the service, treatment, procedure, drugs or supplies are provided; a greater area if necessary to obtain a representative cross-section of charge for a like treatment, service, procedure, device drug or supply.
Reasonable and Customary Charges, Fees or Expenses as used in this, brochure to describe expense will be considered to mean the percentile of the payment system in effect at coverage issue as shown on the Schedule of Benefits.

10. Exclusions

No benefits will be paid for loss or expense caused by, contributed to, or resulting from:

1. Pre-existing Conditions; however, a Pre-Existing Condition will be covered after the person has been continuously insured for 6 months under the same insurance plan;
2. No benefits will be paid for loss or expense caused by, enrolling solely for the purpose of obtaining medical treatment, while on a waiting list for a specific treatment, or while traveling against the advice of a Physician;
3. For routine physical, immunizations or other examination where there are no objective indications or impairment in normal health, and laboratory diagnostic or X-ray examination except in the course of a disability established by the prior call or attendance of a physician;
4. Eye examinations; prescriptions or fitting of eyeglasses and contact lenses;
5. Hearing examinations or hearing aids; or other treatment for hearing defects and problems;
6. Dental treatment, except as the result of Injury to Sound, Natural Teeth as stated in the Covered Medical Expenses;
7. Professional services rendered by a member of the Insured Person's immediate family, or anyone who lives with the Insured Person;
8. Services or supplies not necessary for the medical care of the patient's Injury or Sickness;
9. Weak, strained or flat feet, corns, calluses, or toenails;
10. Cosmetic surgery, or treatment for congenital anomalies (except as specifically provided), except reconstructive surgery as the result of a covered Injury or Sickness. Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or Sickness;
11. Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof;
12. Injury sustained while participating in an amateur, club, intramural, interscholastic, intercollegiate, professional or semi-professional sports;
13. Injury or Sickness for which benefits are paid or payable under any Worker's Compensation or Occupational Disease Law or Act, or similar legislation;
14. Organ transplants;
15. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rate premium will be refunded upon request for such period not covered);
16. Participation in a riot or civil disorder; commission of or attempt to commit a felony in the country in which it was attempted or committed;
17. Suicide or attempted suicide (including drug overdose) while sane or insane (while sane in Missouri); or intentionally self-inflicted Injury (may vary by state);
18. Charges of an institution, health service, or infirmary for whose service payment is not required in the absence of insurance;
19. Loss incurred from riding in any aircraft, other than as a passenger in an aircraft licensed for the transportation of passengers;
20. Duplicate services actually provided by both a certified nurse-midwife and Physician;
21. Expenses payable under any prior policy which was in force for the person making the claim;
22. Expenses incurred during a Hospital emergency room visit which is not of an emergency nature;
23. Expenses incurred for outpatient treatment in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;
24. Medical expense resulting from a motor vehicle accident in excess of that which is payable under any valid and collectible insurance;
25. Pregnancy or childbirth (except when conception occurs while this coverage is in effect); elective abortion; elective cesarean section; pregnancy or childbirth for a dependent when dependent child of an Insured Student (except for complications arising there from;
26. Expenses covered by any other valid and collectible medical, health or accident insurance;
27. Expenses incurred after the date insurance terminates for an Insured Person;
28. Expenses incurred for injuries resulting from the use of alcohol or intoxicants, or any drugs unless prescribed by a Physician;
29. For services, supplies or treatment, including any period of hospital confinement, which were not recommended, approved and certified as necessary and reasonable by a physician;
30. For the ordinary cost of a one way airplane ticket used in the transportation back to the Insured's country where an air ambulance benefit is provided and medically necessary;
31. For specific named hazards: motorcycling, scuba diving, jet, snow or water skiing, ski activity, snowboarding, mountain climbing (where ropes or guides are used), sky diving, professional or amateur racing, piloting an aircraft, bungee jumping, spelunking, whitewater rafting, surfing (unless part of a school credit course), and parasailing;
32. Treatment paid for or furnished under any other individual or group policy, or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government program or facility set up for the treatment without cost to any individual;
33. Treatment of Acne;
34. Elective Surgery and Elective Treatment. For details on what is determined to be Elective Surgery and Elective Treatment contact Klais at (800) 331-1096.
35. Covered medical expenses for which the Covered Person would not be responsible for in the absence of the Master Certificate;
36. Conditions that are not caused by a Covered Accident or Sickness.

11. How to enroll by fax or mail

1. Complete the enrollment form. Answer all questions to avoid delays.
2. Specify the required months of coverage - Minimum 3 months / Maximum 12 months.
3. Multiply number of months by your monthly rate (student / student + spouse / student + family).
4. Total the amounts and please sign the form.
5. Make check payable to ISO.
6. Mail enrollment forms with payment to: ISO, 150 West 30th Street, Suite 1101, New York, NY 10001.
7. When paying by credit card, please include expiration date. You may fax credit card payments with enrollment form to (212) 262-8920.

12. Assistance services

Assistance services are provided by On Call International. An outline of the assistance services appears below

Pre-Travel Assistance

• Help in arranging special medical services needed while traveling

Medical Emergency Services

• Worldwide, 24-hour medical location service
• Medical case monitoring, arrangement of communication between patient, family, physicians, employer, consulate, etc.
• Medical transportation arrangements
• Emergency message service for medical situations

Legal Assistance

• Worldwide, 24-hour contact for non-criminal legal emergencies
• Legal referral to help you locate a consular official or attorney

Travel Assistance

• Help with lost passports, tickets and documents

On Call International

• U.S. or Canada: (8us) 509-7715
• International: Contact International Operator to place your call to (01-603) 328-1728
• E-mail for emergencies to mail@oncallinternational.com

13. Claim procedure

In the event of Sickness or Injury, you should report to the Student Health Service, if available, or the nearest physician or hospital. Persons insured under this plan may choose to be treated within or outside of the First Health/ Multiplan Networks. Reimbursement rates will vary according to the source of care as described under the Summary Schedule of Benefits and Covered Medical Expenses.

Please mail the completed claim form and accompanying documentation to the claims administrator, Klais & Company, Inc., 1867 West Market Street  Akron, OH 44313. The completed claim form, all itemized bills, statements and receipts must be sent to the claims administrator no more than 90 days after a covered loss occurs or end, or as soon after that as is reasonably possible.

Should it become necessary to check upon the status of your filed claim, you may call the claims administrator at (800) 331-1096 between 9:00 A.M. and 5:00 P.M. EST Monday through Friday or e-mail at iso@klais.com. On line claims status via the internet is available 24 hours a day at www.klais.com

14. Underwriter: United States Fire Insurance Company

This brochure provides you with the benefits of Platinum Select insurance plan, as underwritten by United States Fire Insurance Company, by Fairmont Specialty, a part of Crum & Forster.
Please keep this brochure as a summary of the insurance plan as specified in the Master Certificate that is on file with your Program Manager. The Master Certificate contains all of the same terms and conditions outlined in this brochure including: benefits, limitations, and exclusions as underwritten by United States Fire Insurance Company. In the event of a discrepancy, the Master Certificate will prevail.

15. Refund of premium

Premium refunds, less a processing fee, will be considered only for entry into the armed forces. Unearned funds will be refunded, less a $50 processing fee, for the number of full months only. The refund request must be in writing and your Medical Insurance ID card must be returned with your request. Premium refunds will not be considered if a claim has been filed during the Period of Coverage. All refunds are subject to approval by the administrator.

16. Preferred Provider Organization (PPO)

Persons insured under this plan may choose to be treated within or outside of First Health or Multiplan Networks. The Networks consists of hospitals, doctors and other health care providers organized into a network for delivering quality health care at affordable rates.

First Health – to search for participating doctors or hospitals call (800) 226-5116 or www.myfirsthealth.com

Multiplan – to search for participating doctors or hospitals call (888) 342-7427 or www.multiplan.com