Syracuse University International Students

Policy Number

17 STI010042600

Plan Information

Claim Form

Questions?

Call CISI Monday-Friday 9am-5pm ET
800-303-8120

After hours for emergencies
609-986-1234

Email:
medservices@assistamerica.com

World Class Coverage Plan Designed For Syracuse University International Students enrolled in EducationUSA Academy

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

Coverage Summary for Policy #

17 STI010042600

Coverages and Services	Maximum Limits
*Section I*
Accidental Death & Dismemberment	$10,000 (aggregate limit $1,000,000)
Medical Expense (per Accident or Sickness)	$150,000
Deductible	$100, Reduced to $0 if treatment is first sought at the Student Health Center
Dental Emergency of Pain Relief	Up to $500
Accidental Dental	Up to policy max
Mental and Nervous (Per Lifetime):
Outpatient	$2,000
Inpatient	$10,000
Physiotherapy:	If recommended by a physician and administered by a licensed physiotherapist
Specified Therapies and Spinal Manipulation:
Outpatient Limit	Maximum of $50/visit; maximum 10 visits; $500 overall maximum
Sports Related Injuries	Up to $5,000
Emergency Medical Reunion	Up to $2,000 (up to $200 per day)
Emergency Medical Evacuation	$100,000
Repatriation/Return of Mortal Remains	$100,000
24/7 Team Assist Package & CISI In-house Crisis Team	Included

In Case of Emergency

Please contact the Team Assist line by phone at +1 609-986-1234 (collect calls accepted) or email medservices@assistamerica.com. The Team Assist Emergency Assistance Provider is Assist America.
Non-Emergency questions may be directed to CISI at 203-399-5130 (toll free 800-303-8120).

Need a Doctor?

To seek recommendations for doctors or hospitals, please contact Team Assist at (609) 986-1234 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 visit the student health center on campus, your deductible will be reduced to $0. 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.

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