PLATINUM SELECT- ISO's exclusive comprehensive Accident & Sickness insurance plan for international
Underwritten by United States Fire Insurance Company
1. COMPASS PLATINUM monthly rates:
|Student & spouse
|Student & family up to 2 children
|Each additional child
* Minimum enrollment 3 months.
2. Summary schedule of benefits
||In PPO Network
||Out of Network
|Medical expense per injury or sickness
|Lifetime medical maximum
|Maximum out-of-pocket expenses1
||80% of first $4,000; 100% up to $250,000 of PPO Allowance
||70% of Reasonable and Customary charges (R&C) up to $250,000
|. At student health center
|. ER visit (waived if admitted)
||Covered after 6 months
||Covered after 6 months
||Covered as any other sickness
||Covered as any other sickness
|Prescription deductible per fill
|X-ray and labs tests
Repatriation of remains
|Accidental death & dismemberment
1Not including co-payment
2Co-payments are waived if student is treated on site
at student health center and is not referred off campus.
- In case of a student not being able to be treated at health center, and subsequently
referred to off campus private doctor, co-payment will be half of scheduled amount.
- In case of treatment not being possible at student health center and student is
referred to the ER, co-payment will be half of scheduled amount.
- In case of treatment not being available at student health center and student is
referred to the ER and then subsequently hospitalized; ER, doctor's visit and hospitalization
co-payments will be integrated to a maximum of $250 in PPO or $500 elsewhere.
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
Covered Medical Expenses include:
- 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
- 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
- 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.
- Intensive Care.
- 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.
- Physiotherapy. 1 visit per day.
- 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.
- Anesthetist Services: in connection with inpatient surgery.
- 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.
- 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.
- 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
- Mental and Nervous Disorder (inpatient): benefits are limited to 1 visit per day
to a maximum of 30 visits per benefit period.
- 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.
- 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.
- Anesthetist (Outpatient): in connection with outpatient surgery.
- 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.
- 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.
- Radiation Therapy (Outpatient)
- Chemotherapy (Outpatient)
- Prescription Drugs (Outpatient)
- Mental and Nervous Disorder (outpatient): benefits are limited to 1 visit per day
to a maximum of 40 visits per year.
- Ambulance Service.
- 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.
- Consultant Physician Fees: when requested and approved by the attending Physician.
- 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.
- Alcoholism/Drug Abuse Treatment: the benefits and the maximum amounts are specified
in the Schedule of Benefits.
- HIV infection, HIV-related illnesses and AIDS: benefits are limited to a lifetime
maximum of $7,500.
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.
- 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.
- 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:
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
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
||100% of the Principal Sum
|Two or more Members
||100% of the Principal Sum
||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.
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
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:
- The date of departure from your home country/country of permanent residence;
- The date the application form and premium are received by the Underwriting Company
or its designated representative;
- The date requested on the enrollment form.
Coverage will terminate on the earliest of the following:
Extension Of Accident and Sickness Insurance Benefits
- The last day for which premium has been paid;
- The date the Master Certificate terminates;
- The date of entry into active duty military service.
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.
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.
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.
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.
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.
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.
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.
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.
No benefits will be paid for loss or expense caused by, contributed to, or resulting
- 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;
- 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;
- 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;
- Eye examinations; prescriptions or fitting of eyeglasses and contact lenses;
- Hearing examinations or hearing aids; or other treatment for hearing defects and
- Dental treatment, except as the result of Injury to Sound, Natural Teeth as stated
in the Covered Medical Expenses;
- Professional services rendered by a member of the Insured Person's immediate family,
or anyone who lives with the Insured Person;
- Services or supplies not necessary for the medical care of the patient's Injury
- Weak, strained or flat feet, corns, calluses, or toenails;
- 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;
- 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;
- Injury sustained while participating in an amateur, club, intramural, interscholastic,
intercollegiate, professional or semi-professional sports;
- Injury or Sickness for which benefits are paid or payable under any Worker's Compensation
or Occupational Disease Law or Act, or similar legislation;
- Organ transplants;
- 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);
- 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;
- Suicide or attempted suicide (including drug overdose) while sane or insane (while
sane in Missouri); or intentionally self-inflicted Injury (may vary by state);
- Charges of an institution, health service, or infirmary for whose service payment
is not required in the absence of insurance;
- Loss incurred from riding in any aircraft, other than as a passenger in an aircraft
licensed for the transportation of passengers;
- Duplicate services actually provided by both a certified nurse-midwife and Physician;
- Expenses payable under any prior policy which was in force for the person making
- Expenses incurred during a Hospital emergency room visit which is not of an emergency
- 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;
- Medical expense resulting from a motor vehicle accident in excess of that which
is payable under any valid and collectible insurance;
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;
- Expenses covered by any other valid and collectible medical, health or accident
- Expenses incurred after the date insurance terminates for an Insured Person;
- Expenses incurred for injuries resulting from the use of alcohol or intoxicants,
or any drugs unless prescribed by a Physician;
- For services, supplies or treatment, including any period of hospital confinement,
which were not recommended, approved and certified as necessary and reasonable by
- 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
- 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),
- 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;
- Treatment of Acne;
- Elective Surgery and Elective Treatment. For details on what is determined to be
Elective Surgery and Elective Treatment contact Klais at (800) 331-1096.
- Covered medical expenses for which the Covered Person would not be responsible for
in the absence of the Master Certificate;
- Conditions that are not caused by a Covered Accident or Sickness.
11. How to enroll by fax or mail
- Complete the enrollment form. Answer all questions to avoid delays.
- Specify the required months of coverage - Minimum 3 months / Maximum 12 months.
- Multiply number of months by your monthly rate (student / student + spouse / student
- Total the amounts and please sign the form.
- Make check payable to ISO.
- Mail enrollment forms with payment to: ISO, 150 West 30th Street, Suite 1101, New
York, NY 10001.
- 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
- 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
- Worldwide, 24-hour contact for non-criminal legal emergencies
- Legal referral to help you locate a consular official or attorney
- 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 email@example.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 firstname.lastname@example.org.
On line claims status via the internet is available 24 hours a day at www.klais.com
14. Underwriter: United States Fire
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.
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
The amount of money you have to pay the service provider before insurance coverage
The percentage of coverage the insurance company pays Medical evacuation
The amount of coverage for medically necessary transportation: ambulance, air rescue,
etc. Repatriation of remains
The amount of coverage for transporting the body of a deceased person back home.
means the fee you pay for certain medical services or prescription drugs. For example,
you may pay $10 to fill a prescription and the health plan covers the balance of