Arkansas State University

Policy Number

STB009996902

Plan Information

Claim Form

Emergency Flyer

Questions?

Contact CISI:

+1 800-303-8120

E-mail:
Claimhelp@mycisi.com

World Class Coverage Plan Designed For Arkansas State University

This plan is provided by Cultural Insurance Services International and underwritten by Arch Insurance

Coverage Summary for Policy #

STB009996902

Coverages and Services	Maximum Limits
Accidental Death & Dismemberment:
Aggregate Limit Per AccidentPer Insured	$10,000 (aggregate limit $1,000,000)
Medical Expense (per Accident or Sickness):	$100,000 @ 100%
Deductible	$0 (zero)
Mental and Nervous:
Outpatient	Up to $2,000
Inpatient	Up to $5,000
Specified Therapies and Spinal Manipulation:
Outpatient Limit	Up to $500 max, $50 per visit, max 10 visits/incident
Accidental Dental	Up to Accident Medical Expense Limit
Dental, Relief of Pain	Up to $500 max ($250 per tooth)
Limit for:
Emergency Medical Evacuation	$100,000
Repatriation/Return of Mortal Remains	$100,000
Pre-Existing Coverage	Up to $500
24/7 Team Assist Package & CISI Crisis Team	Included
CISI In-House Crisis Team	Included
Emergency Medical Reunion	Up to $2,500 ($200/day)
Baggage and Personal Effects (checked with common carrier)	$50 deductible, $100 per article up to $200 maximum
Comprehensive Security Evacuation	$100,000 per insured

What do to in case of a minor injury or illness

We are always happy to pay a foreign provider directly. Many foreign providers, however, prefer payment from the patient when services are rendered. Students and faculty using this insurance should be prepared to pay for doctor visits for minor illnesses such as a sore throat or a sinus infection, for example. However, even for a minor illness, if the overseas doctor is willing to bill us directly, we are willing and able to pay them directly for covered medical expenses (this is always up to the provider). CISI's billing address and claim help # is on each ID card and on the claim form which is part of the brochure. If medical expenses are incurred while abroad, the claim form and scanned copies of the itemized paid bill(s) can be emailed to claimhelp@mycisi.com. Claims should be submitted for processing as soon as possible (and no later than one year after treatment was received, if possible). Claims are typically processed within 15 business days provided CISI has all of the information needed for reimbursement. A case does not need to be opened in advance in order for us to pay a claim for covered expenses for minor injuries/illnesses. Team Assist (our 24/7 assistance provider) can help provide referrals to doctors/hospitals if needed but insureds may visit any provider they would like and eligible expenses will be covered at 100% (in other words, CISI does not have network restrictions).

What do to in case of a serious injury or illness

For all emergencies, seek help without delay at the nearest facility and then, after admittance, open up a case with Team Assist (our 24/7 assistance provider). To avoid any delay in treatment, the insured (or someone with the insured) may need to provide a personal payment method to the hospital up front. Once a case is opened, however, it is always our goal to have the hospital or facility bill us directly so that neither the program/sponsor/school nor the insured needs to provide payment. In these types of situations, the insured (or someone calling on his/her behalf) needs to open a medical file with Team Assist asking for help with this. If personal payment has already been processed, we can expedite reimbursement. Team Assist (our medical/travel/technical partner) and i-JET (our security partner) are both 24/7 operations. To keep things simple for our insureds, the number to call for a medical/travel/technical issue is the same as for a security related issue. The toll-free 800 and non-800 (when calling from overseas) numbers for Team Assist are provided below as well as on the front of the ID card and in the brochure under the claim form. On the claim form and back of the ID card we list CISI's claim help line and e-mail address which are answered from 9-5 EST M-F. Team Assist has 24/7 access to our enrollment database and also has access to each group's coverage information. If a benefit or claim related call or e-mail comes to Team Assist during our business hours it is usually transferred to us. After hours and on weekends, Team Assist handles the communications and involves our Claims Operations Manager as needed 24/7.

Questions?

Schedule of Benefits
Benefits	Limits
Medical Expenses Limits:
Lifetime/Annual Maximum	Unlimited
Per Accident or Sickness	$250,000
Per Occurrence Deductibles:
Emergency Room Deductible (waived if admitted)	$250
Call-A-Doc	$0
Physician/Outpatient/Dr. Visit	$100
Urgent Care	$50
Walk in Clinic	$25
MRI/CAT Scan	$0
Rx Copay	$0
Pre-Existing Conditions-12 Month Look Back; thereafter up to policy max	Up to $500
Coinsurance Percentage (%)	100% Coinsurance
Prescription Drugs (inpatient/outpatient)	Inpatient: 100% of Covered Expenses Outpatient: 100% of Covered Expenses
Mental Health	Inpatient up to 30 days/Outpatient 30 visits
Pregnancy (conception must occur while covered under this plan)	Treated as any other illness
Physiotherapy	Covered
Chiropractic Care & Therapeutic Services	Up to $500 max, $50 per visit
Emergency Reunion	$15,000 (hospitalized 3 days)
Home Country (Incidental Trips)	$1,000
Trip Delay (applies mid trip as well) 24-hour time	Up $1,500/daily limit $100
Political Evacuation	$10,000
Dental Injury Only	Up to policy max
Palliative Dental	$1,000max/$200 per tooth
24/7 Assistant Services & In-house Crisis Team	Included
Medical Evacuation	$50,000
Repatriation of Remains	$25,000
Accidental Death & Dismemberment	$15,000 ($1M aggregate limit)

Schedule of Benefits
Benefits	Limits
Medical Expenses Limits:
Lifetime/Annual Maximum	Unlimited
Per Accident or Sickness	$2,000,000
Per Occurrence Deductibles:
Emergency Room (waived if admitted)	$250
Call-A-Doc	$0
Physician/Outpatient/Dr. Visit	$50
Urgent Care	$50
Walk in Clinic	$25
MRI/CAT Scan	$0
Rx Copay	$0
Pre-Existing Conditions-12 Month Look Back; thereafter up to policy max	Up to $500
Coinsurance Percentage (%)	100% Coinsurance
Prescription Drugs (inpatient/outpatient)	Inpatient: 100% of Covered Expenses Outpatient: 100% of Covered Expenses
Mental Health	Inpatient up to 30 days/Outpatient 30 visits
Pregnancy (conception must occur while covered under this plan)	Treated as any other illness
Emergency Reunion	$15,000 (hospitalized 3 days)
Physiotherapy	Covered
Chiropractic Care & Therapeutic Services	Up to $500 max, $50 per visit
Home Country (Incidental Trips)	$1,000
Trip Delay (applies mid trip as well) 24-hour time	Up $1,500/daily limit $100
Political Evacuation	$10,000
Dental Injury Only	Up to policy max
Palliative Dental	$1,000max/$200 per tooth
24/7 Assistant Services & In-house Crisis Team	Included
Medical Evacuation	$50,000
Repatriation of Remains	$25,000
Accidental Death & Dismemberment	$15,000 ($1M aggregate limit)
Trip Interruption	$1,000
Personal Liability
Personal Liability Limit	$2,000,000
Liability deductible	$100
Medical Payments to Others	$25,000
Additional Living Expenses	$10,000
Payment of Homeowners Deductible	$1,000
Personal Property	$1,500