Colorado School of Mines – Office of Global Education

Policy Number

GLM N16816826

Plan Information

Plan Information – Spain Participants (Requiring a Visa)

Claim Form

Claim Form Spain Participants (Requiring a Visa)

Dependent Enrollment Form

Dependent Enrollment Form– Spain Participants (Requiring a Visa)

Questions?

24/7 Emergency
Assistance – Team Assist
Phone: +1 855-327-1411
(in U.S.)
+001 312-935-1703
(call collect from outside the U.S.)
Email:
medassist-usa@axa-assistance.us

Benefit or Claim Questions?
Contact CISI
(9AM-5PM EST Mon-Fri)
Phone: 1-203-399-5130
(toll free 800-303-8120)
Email: Claimhelp@mycisi.com

World Class Coverage Designed for Colorado School of Mines – Office of Global Education

All Participants, except for
those who require a visa for Spain

Rates

Trips up to 2 weeks in duration: $25.73

Trips over 2 weeks in duration: $52.30/month

Enroll Now

Participants who require a visa
for Spain (90+ Days)

Rates

Trips up to 2 weeks in duration: $29.20

Trips over 2 weeks in duration: $59.36/month

Enroll Now

Coverage Summary for Policy #

GLM N16816826

Schedule of Benefits

Coverages and Services	Maximum Limits
Accidental Death and Dismemberment Per Insured Person	$10,000
Medical expenses (per Covered Accident or Sickness):
Deductible	zero
Benefit Maximum	$100,000 at 100%
Benefit Maximum for Spain participants (90+days Visa Requirement)	Unlimited
Extension of Benefits	30 days
Emergency Medical Reunion	$3,000 (incl. hotel/meals, max $300/day)
Quarantine	$2,000 ($200/day, max 10 days)
Trip Delay	$1,000 ($200/day)
Trip Interruption	$1,000
Team Assist Plan (TAP): 24/7 medical, travel, technical assistance
Emergency Medical Evacuation	$200,000
Repatriation/Return of Mortal Remains	$100,000
Security Evacuation (Comprehensive) * Aggregate of $1M	$100,000

In Case of Emergency

Please contact the Team Assist line by phone at +1 312-935-1703 (collect calls accepted) or email medassist-usa@axa-assistance.us. The TeamAssist Emergency Assistance Provider is AXA Assistance.
Non-Emergency questions may be directed to CISI at 203-399-5130 (toll free 800-303-8120).

Need a Doctor?

Who Pays for Services?

CISI will make every effort to pay invoices directly to medical providers. Please notify CISI by contacting TeamAssist and we will make every effort to arrange to pay the doctor or hospital directly. If you prefer to pay yourself, then we will reimburse you (you may scan/email or fax the claim information to CISI and we will process it while you are still abroad, OR you may file the claim information after your trip). The average claim processing time at CISI is 2 weeks from receipt of claim information.

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