Student Health Advantage Platinum Insurance

• Intercollegiate / Interscholastic / Intramural or Club Sports help	Period of Coverage Limit per illness or injury: $5,000 In-Network: 90% Out-of-Network: 80% International: 100%
  Dental Treatment help	Period of Coverage Limit: $350 (Treatment due to Unexpected pain to sound, natural teeth) Period of Coverage Limit per Injury: $500 (Non-emergency Treatment at a Dental Provider due to an Accident)
  Eligible Medical Expenses	In-Network: 90% Out-of-Network: 80% International: 100%
  Intensive Care help	In-Network: 90% Out-of-Network: 80% International: 100%
  Maternity and Newborn Care help	Maximum Limit: $5,000 Pre-natal care, delivery of a Newborn, and post-natal care of an Insured Person, including complications Newborn routine care during the first 31 days of life
  Hospital Emergency Room help	Not subject to Emergency Room Deductible Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission.
  Hospital Room and Board help	Average semi-private room rate Includes nursing, miscellaneous and Ancillary Services
  Outpatient Surgical / Hospital Facility help	In-Network: 90% Out-of-Network: 80% International: 100%
  Laboratory help	In-Network: 90% Out-of-Network: 80% International: 100%
  Chemotherapy / Radiation Therapy help	In-Network: 90% Out-of-Network: 80% International: 100%
  Pre-Admission Testing	In-Network: 90% Out-of-Network: 80% International: 100%
  Reconstructive Surgery help	Surgery is incidental to and follows Surgery that was covered under the plan
  Assistant Surgeon help	20% of the primary surgeon’s eligible fee
  Anesthesia help	In-Network: 90% Out-of-Network: 80% International: 100%
  Durable Medical Equipment help	In-Network: 90% Out-of-Network: 80% International: 100%
  Chiropractic Care help	Medical order or Treatment plan required In-Network: 90% Out-of-Network: 80% International: 100%
  Extended Care Facility help	Upon direct transfer from an acute care Facility In-Network: 90% Out-of-Network: 80% International: 100%
  Home Nursing Care help	Provided by a Home Health Care Agency Upon direct transfer from an acute care Facility
  Physician Visits help	Maximum Visits per day: 1 Surgery is not subject to the Maximum visit limit.
  Telehealth	Groups Only Not subject to Deductible and Coinsurance Mental or Nervous Disorders are not covered Coverage for Telehealth is not a determination that any specific condition discussed, raised or identified during such consultation is covered under this insurance. The Company reserves the right to decline future claims relating to or arising from any condition discussed, raised or identified during Telehealth where the Illness or Injury is directly or indirectly related to any Pre-existing Condition or is otherwise excluded under this Certificate of Insurance
  Traumatic Dental Injury help	Treatment at a Hospital Facility due to an Accident Additional Treatment for the same Injury rendered by a Dental Provider will be paid at 100%

• Terrorism help	Not subject to Deductible and Coinsurance Maximum Limit: $50,000
  Emergency Medical Evacuation	Maximum Limit: $500,000 Must be approved in advance and coordinated by the Company
  Emergency Local Ambulance help	Period of Coverage Limit per Injury $750 Period of Coverage Limit per Illness $750 (resulting in an Inpatient
  Emergency Reunion help	Maximum Limit: $50,000 Maximum Days: 15 Meal Maximum per day: $25 Reasonable and necessary travel costs and accommodations Must be approved in advance by the Company
  Interfacility Ambulance Transfer help	Up to the per Injury or Illness limit Services rendered in the United States Transfer must be a result of an Inpatient Hospital admission
  Political Evacuation & Repatriation help	Maximum Limit: $10,000 Must be approved in advance by the Company
  Repatriation for Medical Treatment	Maximum Benefit: $100,000. This is in addition to the plan maximum limit/per injury or illness maximum limit Approved in advance and coordinated by the Company Refer to the REPATRIATION FOR MEDICAL TREATMENT provision for further details
  Return of Mortal Remains or Cremation/Burial help	Maximum Limit: $50,000 Local Burial / Cremation at place of death Maximum Limit: $5,000 Return of Insured Person’s Mortal Remains to Country of Residence Must be approved in advance by the Company

• Incidental Trip	Maximum days: 14 Country of Residence is outside the United States Refer to the INCIDENTAL TRIP provision for further details
  Accidental Death & Dismemberment help	Not subject to Deductible and Coinsurance Death must occur within 90 days of the Accident Accidental Death: 100% of Principal Sum Student: $25,000 Spouse: $10,000 Child: $5,000
  Personal Liability help	Secondary to any other insurance No coverage for Injury to a related Third Party or damage to related Third Person’s property Combined Maximum Limit: $10,000 Injury to Third Person: Per Injury Deductible: $100 Damage to Third Person’s property: Per damage Deductible: $100

• Mental/Nervous

  Inpatient Mental or Nervous / Substance Abuse: Maximum Limit: $10,000 Not covered if incurred at the Student Health Center Outpatient Mental or Nervous / Substance Abuse: Maximum Limit per day: $50 Maximum Limit: $500 Not covered if incurred at the Student Health Center

• Pre-Existing Conditions help

  Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded until the Insured Person has maintained 6 months of continuous coverage under this insurance.

*Note: Benefit amounts shown are based on In-Network coverage. Please consult your specific policy documents for precise coverage limits, benefits and exclusions. Optional add-on benefits are available for an additional charge.

Student Health Advantage insurance can purchase an optional rider at the time of application. The optional riders provide additional coverage for a minimal charge.