Bellarmine University International Students

Policy Number

STI009997100

Plan Information

Claim Form

Security Evacuation

Questions?

Call Team Assist:

(609) 986-1234

Email:

medservices@assistamerica.com

World Class Coverage Plan Designed For Bellarmine University International Students

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

Coverage Summary for Policy #

STI009997100

Coverages and Services	Maximum Limits
Section I
Medical Expense(per Accident or Sickness):
Deductible	$100
If first treated at the student health center deductible reduced to	$0
Emergency Room Deductible if Non-Emergent	$250
Basic Medical	$200,000 at 80%
Emergency Medical Reunion Benefits	up to $3,000
Trip Interruption	up to $2,000
Baggage and Personal Effects ($50 deductible, $100 per article)	up to $3,000
Section II
Team Assist Plan 24-7 Medical, Travel, technical Assistance:
Emergency Medical Evacuation/Repatriation	$150,000
Return of Mortal Remains	$150,000

In Case of Emergency

Need a Doctor?

To seek recommendations for doctors or hospitals, please contact Team Assist at (609) 986-1234 (collect calls accepted) or email medservices@assistamerica.com. *We can make appointments for you. Or, you may search for a facility within your area by going to www.myfirsthealth.com On this page you can enter your zip code or city. It will pull a list of facilities that are part of the First Health Network. These are facilities that will work directly with CISI.

Who Pays for Services?

If you visit a facility that is part of the First Health Network, the facility will bill CISI directly. After your visit, you will receive an Explanation of Benefits. This document will outline what CISI paid and what you owe directly to the Facility. For covered expenses, you will be responsible for the deductible, which is $100.00. This is the amount that you are responsible for. If you pay for your bill at the time of your visit, we will reimburse you (you may scan/email or fax the claim information to CISI and we will process it for you. The average claim processing time at CISI is 2 weeks from receipt of claim information.

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