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RPI Final


  • pg 1
									        Student Accident
           & Sickness
         Insurance Plan

                (“the Policyholder”)

 Administrator Policy Number CHH0071061
 Underwriter Reference Number CAS9499769

                   Underwritten by:
        National Union Fire Insurance Company
                   of Pittsburgh, Pa.
with its principal place of business in New York, NY

This brochure is a brief description of the Student
Accident and Sickness Insurance Plan available under
policy series S30494NUFIC-NY. The Policy may con-
tain definitions, reductions, limitations, exclusions and
termination provisions. Full details of the coverage are
contained in the Policy on file with the Policyholder. If
there is any conflict between the contents of this docu-
ment and the Policy, the Policy will govern in all cases.

The Policy does not cover nor provide benefits for
treatment arising out of participation in extra-hazardous
activities. Extra-hazardous activities means aviation and
related activities, such as skydiving and parachuting,
and participation as a professional in athletics or sports.
 RENSSELAER POLYTECHNIC INSTITUTE (RPI)                         coursework, have passed their qualifying examinations
   STUDENT ACCIDENT AND SICKNESS PLAN                           (applies only to Ph.D. students), are physically located
This is a brief description of the Student Accident and         off campus, and are not eligible to use institutional
Sickness Plan available for RPI students and their              resources may enroll on a voluntary basis.
eligible dependents. The plan is underwritten by National
Union Fire Insurance Company of Pittsburgh, Pa. (“the           ALL ELIGIBLE STUDENTS: For detailed informa-
Company”). The exact provisions governing this                  tion regarding the enrollment process, please go to
insurance are contained in the Policy issued to RPI.            www.maksin.com/RPI.aspx.
                                                                An eligible student must actively attend classes for at
                                                                least the first 31 days of the period for which he or she is
The Gallagher Student Health Center is located on the           enrolled. Except in the case of withdrawal due to
3000 level of Academy Hall. The Student Health Center           Sickness or Injury, any student withdrawing from school
is a comprehensive, nationally accredited physician
directed program providing outpatient ambulatory health         during the first 31 days of the period for which he or she
care. Services include medical, gynecology, and allergy         is enrolled will not be covered under the Policy and a full
clinics, counseling services, and health education and          refund of premium will be made, less any claims paid.
wellness programs. Specialty consultation and referrals         Students who withdraw after such 31 days will remain
are available.                                                  covered under the Policy and no refund will be made.
                                                                Home study, correspondence, Internet and television
During the academic semester, the Student Health Center         (TV) courses do not fulfill the eligibility requirements
is open Monday through Friday from 8:00am to 5:00pm             that the student actively attended classes.
and Saturday and Sunday from 10:00am to 1:30pm. To
make a medical appointment, please call (518) 276-6287.         Eligibility requirements must be met each time premium
The Health Center is open from 8:00am to 4:30pm on              is paid to continue coverage. The Company maintains the
breaks during and between semesters. In the event of an         right to investigate student status and attendance records
emergency, call 911 or dial 6611 from any campus phone          to verify that the Policy eligibility requirements have
to contact RPI’s Department of Public Safety.                   been met. If it is discovered that the Policy eligibility
                                                                requirements have not been met, the Company’s only
                      ELIGIBILITY                               obligation is to refund premium less any claims paid.
All Troy campus full-time registered undergraduate and
graduate students will be automatically enrolled in the         Covered students may also enroll their lawful spouse,
Student Accident and Sickness Plan described in this            same sex domestic partner and/or dependent children to
brochure and the premium will be added to the student           age 19 who are unmarried and fully supported by the
bill unless proof of other comparable coverage is provid-       Covered Student. Dependents must enroll for the same
ed. A student, who initially waived coverage under the          coverage term for which the Covered Student enrolls. An
Policy but subsequently experiences ineligibility under         eligible student may enroll his or her dependents for cov-
another creditable plan may elect to enroll for coverage        erage by the enrollment deadline, or within 30 days of
under the Policy within 30 days of the date of ineligibility    marriage, birth, or adoption, for which proof is required,
under the other creditable plan. Proof is required at time      by going to www.maksin.com/RPI.aspx.
of enrollment.
                                                                     EFFECTIVE AND TERMINATION DATES
Part-time students (matriculated for at least 6 credits),
graduate students physically attending classes at RPI           The Master Policy becomes effective at 12:01 a.m. on
who are registered in a non-credit bearing status while         May 1, 2010 and it terminates at 12:01 a.m. on August
completing requirements for their degree (e.g., thesis or       15, 2011. Coverage for the Covered Person will be effec-
dissertation), and all students registered for classes at the   tive on the Policy Effective Date; the Effective Date of
Hartford Campus may enroll on a voluntary basis.                the coverage term elected; or the day after the date the
                                                                enrollment form and correct premium are received,
TROY CAMPUS ONLY: Graduate students who are                     whichever is later. Coverage terminates for the Covered
primarily engaged in pursuing research-based degrees            Person on the earlier of a) the date the Policy terminates;
(Ph.D. and certain M.S. degrees), have completed their          b) the last day for which premium has been paid; or, c)

                             2                                                               3
the date he or she enters the armed forces. Covered         treatment from a non-participating provider, benefits will
Persons entering the armed forces of any country will not   be reduced to the percentage shown in the Schedule of
be covered under the Policy as of the date of such entry.   Benefits. If a Covered Person is referred by a PPO
A pro-rata refund of premium will be made to such           provider to another provider or facility, it does not mean
persons when written request is made within 90 days of      that the provider or facility to which the Covered Person
leaving school. No other refunds of premiums will be        is referred is also a PPO provider. It is the Covered
allowed.                                                    Person’s responsibility to verify that the provider is part
                                                            of the PPO. A list of nationwide PHCS Preferred
        WAIVER PROCESS/PROCEDURE                            Providers is available for your review via the internet at
Students, who are currently insured by a health insurance   www.multiplan.com. Click on the logo provided on your
policy may waive out of the Student Accident and            ID card. NOTE: If treatment is received in a non-net-
Sickness Plan with proof of comparable coverage.            work facility due to an Emergency Medical Condition,
The waiver form must be completed online at                 benefits for Eligible Expenses are payable at the in-net-
www.maksin.com/RPI.aspx. Online waivers must be             work level of benefits.
completed by the waiver deadline in order to have the
premium removed from the student bill. Failure to meet
                                                                        REFERRAL REQUIREMENT
the waiver deadline will result in the student being
responsible for the insurance premium.                      A referral from the Student Health Center is required
                                                            before benefits are payable. This requirement does not
                Waiver Deadlines                            apply if:
Fall Semester:                September 15, 2010
                                                            (a) the Student Health Center is closed;
*Spring/Summer Semester:      February 15, 2011
                                                            (b) medical care is received when Student is more than
                                                                25 miles from campus;
               QUALIFYING EVENTS                            (c) medical care is obtained by a Student who is not
                                                                eligible to use the Student Health Center;
Students and dependents who are eligible to enroll on a
voluntary basis may do so by completing the enrollment      (d) for maternity;
process online at www.maksin.com/RPI.aspx. Enroll-          (e) for two annual primary and preventive obstetric and
ment must be completed by the open enrollment dead-             gynecologic services examination or any care
line. Open enrollment will end September 15, 2010 for           related to a pregnancy; or
the Fall Semester or February 15, 2011 for the              (f) for Emergency Medical Condition however, the
Spring/Summer Semester*. No enrollment will be                  Student must return to the Student Health Center for
accepted after these enrollment deadlines. The only             referral or necessary follow-up care.
exceptions are the following qualifying events with the
appropriate documentation: (1) adding a new spouse or       Benefits for Eligible Expenses incurred for medical care
dependent child within 30 days of marriage, birth or        or treatment rendered for which no referral is obtained
adoption; or (2) within 30 days of ineligibility under      will be excluded from coverage. This referral require-
another creditable plan. Premiums are not pro-rated.        ment does not apply to the Covered Student’s depen-
       Private Healthcare Systems (PHCS)
   Questions regarding PPO providers, call or visit:
                   1-888-560-7427                           Accident means an occurrence which (a) is unforeseen;
            Website: www.multiplan.com                      (b) is not due to or contributed to by Sickness or disease
The medical benefits stated in this plan are based upon     of any kind; and (c) causes Injury.
medical treatment being received from a Preferred
Provider Organization (PPO). If a Covered Person seeks      Actual Charge means the charge for the covered service
                                                            by the provider who furnishes it.
*Spring/Summer Semester available only to new
 students to RPI.
                           4                                                            5
Allowable Charges means the charges agreed to by the            Emergency Medical Condition means a Sickness or
Preferred Provider Organization for specified covered           Injury for which immediate medical treatment is sought
medical treatment, services and supplies.                       at the nearest available facility. The condition must be
                                                                one which manifests itself by acute symptoms which are
Biologically based mental illness means a mental,               sufficiently severe (including severe pain) that without
nervous, or emotional disorder caused by a biological           immediate medical care could reasonably be expected to
disorder of the brain which results in a clinically             result in any of the following:
significant, psychological syndrome or pattern that sub-        (a) the Covered Person’s life could be in serious
stantially limits the functioning of the person with the ill-   jeopardy; (b) bodily functions would be seriously
ness. The following disorders covered by this definition        impaired; or (c) a body organ or part would be seriously
are: schizophrenia/psychotic disorders; major depression;       damaged; or (d) serious disfigurement.
bipolar disorder; delusional disorders; panic disorder;
obsessive compulsive disorders; anorexia; and bulimia.          Emergency does not include the recurring symptoms of a
                                                                chronic illness or condition unless the onset of such
Covered Person means a Covered Student while cover-             symptoms could reasonably be expected to result in the
age under the Policy is in effect and those dependents          complications listed above.
with respect to whom a Covered Student is insured.
                                                                Experimental/Investigational means a drug, device or
Doctor means: (a) legally qualified physician licensed by       medical care or treatment that meets the following:
the state in which he or she practices; and (b) a practi-       (a) the drug or device cannot be lawfully marketed with-
tioner of the healing arts performing services within the       out approval of the U.S. Food and Drug Administration
scope of his or her license as specified by the laws of the     and approval for marketing has not been given at the time
state of such practitioner; and (c) certified nurse mid-        the drug or device is furnished; (b) the informed consent
wives and licensed midwives while acting within the             document used with the drug, device, medical care or
scope of that certification. The term “Doctor” does not         treatment states or indicates that the drug, device,
include a Covered Person’s immediate family member.             medical care or treatment is part of a clinical trial, exper-
                                                                imental phase or investigational phase, if such a consent
Elective Treatment means medical treatment, which is            document is required by law; (c) the drug, device,
not necessitated by a pathological change in the function       medical care or treatment or the patient’s informed
or structure in any part of the body, occurring after the       consent document used with the drug, device, medical
Covered Person’s effective date of coverage.                    care or treatment was reviewed and approved by the
Elective treatment includes, but is not limited to: tubal       treating facility’s Institutional Review Board or other
ligation; vasectomy; breast reduction unless as a result of     body serving a similar function, if federal or state law
mastectomy; sexual reassignment surgery; submucous              requires such review and approval; (d) reliable evidence
resection and/or other surgical correction for deviated         shows that the drug, device or medical care or treatment
nasal septum, other than necessary treatment of covered         is the subject of ongoing Phase I or Phase II clinical
acute purulent sinusitis; treatment for weight reduction;       trials, is the research, experimental study or investiga-
learning disabilities; immunizations; treatment of infer-       tional arm of ongoing Phase III clinical trials, or is other-
tility and routine physical examinations.                       wise under study to determine its maximum tolerated
                                                                dose, its toxicity, its safety, it efficacy or its efficacy as
Eligible Expense means a charge for any treatment,              compared with a standard means of treatment or
service or supply which is performed or given under the         diagnosis; or (e) reliable evidence shows that the prevail-
direction of a Doctor for the Medically Necessary treat-        ing opinion among experts regarding the drug, device,
ment of a Sickness or Injury: (a) not in excess of the          medical care or treatment is that further studies or clinical
Reasonable and Customary charges; or (b) not in excess          trials are necessary to determine its maximum tolerated
of the charges that would have been made in the absence         dose, its toxicity, its safety, its efficacy or its efficacy as
of this coverage; (c) is the negotiated rate, if any and        compared with standard means of treatment of diagnosis.
(d) incurred while the Policy is in force as to the Covered
Person except with respect to any expenses payable              Reliable evidence means: published reports and articles
under the Extension of Benefits Provision.                      in authoritative medical and scientific literature; written

                             6                                                                7
protocol or protocols by the treating facility studying         A service or supply will not be considered as Medically
substantially the same drug, device, medical care or            Necessary if: (a) it is provided only as a convenience to
treatment; or the written informed consent used by the          the Covered Person or provider; or (b) it is not the
treating facility or other facility studying substantially      appropriate treatment for the Covered Person’s diagnosis
the same drug, device or medical care or treatment.             or symptoms; or (c) it exceeds (in scope, duration or
Covered Expenses will be considered in accordance with          intensity) that level of care which is needed to provide
the drug, device, medical care or treatment at the time the     safe, adequate and appropriate diagnosis or treatment; or
Expense is incurred.                                            (d) it is Experimental/Investigational or for research
                                                                purposes; or (e) could have been omitted without
Hospital means a short-term, acute, general hospital,           adversely affecting the patient’s condition or the quality
which:                                                          of medical care; or (f) involves treatment of or the use of
(a) is primarily engaged in providing, by or under the          a medical device, drug or substance not formally
continuous supervision of Doctors, to inpatients,               approved by the U.S. Food and Drug Administration
diagnostic services and therapeutic services for diag-          (FDA); or (g) involves a service, supply or drug not
nosis, treatment and care of injured and sick persons;          considered reasonable and necessary by the Healthcare
(b) has organized departments of medicine and major             Financing Administration Medicare Coverage Issues
surgery; (c) has a requirement that every patient must be       Manual or Center for Medicare and Medicaid Services
under the care of a Doctor or dentist; (d) provides 24-         Issues Manual; or (h) it can be safely provided to the
hour nursing service by or under the supervision of a reg-      patient on a more cost-effective basis such as outpatient,
istered professional nurse (R.N.); (e) if located in New        by a different medical professional or pursuant to a more
York State, has in effect a hospitalization review plan         conservative form of treatment.
applicable to all patients which meets at least the stan-       The fact that any particular Doctor may prescribe, order,
dards set forth in section 1861(k) of United States Public      recommend, or approve a service or supply does not, of
Law 89-97, (42 USCA 1395x[k] ); (f) is duly licensed by         itself, make the service or supply Medically Necessary.
the agency responsible for licensing such hospitals; and
(g) is not, other than incidentally, a place of rest, a place   Mental or Nervous Disorder(s) means any condition or
primarily for the treatment of tuberculosis, a place for the    disease regardless of its cause, listed in the most recent
aged, a place for drug addicts, alcoholics, or a place for      edition of the American Psychiatric Association
convalescent, custodial, educational, or rehabilitative         Diagnostic and Statistical Manual of Mental Disorders
care.                                                           (other than those conditions caused by Biologically
Hospital also includes tax-supported institutions, which        Based Mental Illness, or with respect to a dependent
are not required to maintain surgical facilities.               child under age eighteen (18), Serious Emotional
                                                                Disturbance on the date the medical care or treatment is
Injury means bodily injury due to an Accident which:            rendered to the Covered Person.
(a) results solely, directly and independently of disease,
bodily infirmity or any other causes; (b) occurs after the      Musculoskeletal Therapy means the diagnosis and
Covered Person’s effective date of coverage; and                treatment, by manual or mechanical means, of the mus-
(c) occurs while coverage is in force. All injuries             culoskeletal structure due to lack of normal nerve, mus-
sustained in any one Accident, including all related            cle, and/or joint function following an Injury.
conditions and recurrent symptoms of these injuries, are
considered one Injury.                                          Pre-Existing Condition means a Sickness, Injury or
                                                                condition, whether physical or mental, regardless of its
Medical Necessity/Medically Necessary means that a              cause, for which medical advice, diagnosis, care or
drug, device, procedure, service or supply is necessary         treatment was recommended or received within the 6
and appropriate for the diagnosis or treatment of a             month period ending on the Covered Person’s effective
Sickness or Injury based on generally accepted current          date of coverage under the Policy or a pregnancy existing
medical practice in the United States at the time it is pro-    on the Covered Person’s effective date of Coverage under
vided.                                                          the Policy. Genetic information shall not be treated as a
                                                                pre-existing condition in the absence of a diagnosis of the
                                                                condition related to such information.

                             8                                                              9
Reasonable and Customary (R&C) means the charge,             Urgent Condition means a sudden illness, Injury, or
fee or expense which is the smallest of: (a) the actual      condition, that: (a) is severe enough to require prompt
charge; (b) the charge usually made for a covered service    medical attention to avoid serious deterioration of the
by the provider who furnishes it; (c) the negotiated rate,   Covered Person’s health; (b) includes a condition which
if any; and (d) the prevailing charge made for a covered     would subject the Covered Person to severe pain that
service in the geographic area by those of similar profes-   could not be adequately managed without urgent care or
sional standing. “Geographic area” means the three digit     treatment; (c) does not require the level of care provided
zip code in which the services, procedure, devices, drugs,   in the emergency room of a Hospital; and (d) requires
treatment or supplies are provided or a greater area, if     immediate outpatient medical care that cannot be
necessary, to obtain a representative cross-section of       postponed.
charge for a like treatment, service, procedure, device,
drug or supply. Reasonable and Customary charges also        Urgent Care Provider means (a) a freestanding medical
means the percentile of the payment system in effect on      facility which: (1) provides unscheduled medical
the Effective Date shown in the Schedule of Benefits.        services to treat an Urgent Condition; (2) routinely pro-
                                                             vides ongoing unscheduled medical services for more
Serious Emotional Disturbances - applicable only to          than 8 consecutive hours; (3) makes charges; (4) is
children under age eighteen (18), means a child who has      licensed and certified as required by any state or federal
a diagnosis of attention deficit disorder, disruptive        law or regulation; (5) keeps a medical record on each
behavior disorder, or pervasive development disorder         patient; (6) provides an ongoing quality assurance
and one or more of the following: serious suicidal           program (this includes reviews by Doctors other than
symptoms or other life-threatening self-destructive          those who own or direct the facility); (7) is run by a staff
behavior; significant psychotic symptoms (hallucina-         of Doctors, at least one of whom is on call at all times;
tions, delusion, bizarre behavior); behavior caused by       (8) has a full-time administrator who is a Doctor; or (b) a
emotional disturbance that places the child at risk of       Doctor’s office.
causing personal injury or significant property damage;
or behavior caused by emotional disturbance that places      It is not the emergency room or outpatient department of
the child at substantial risk of removal from the house-     a Hospital.
                                                                    PRE-NOTIFICATION REQUIREMENT
Sickness means disease or illness including related          All inpatient stays should be reported.
conditions and recurrent symptoms of the Sickness.
Sickness also includes pregnancy and complications of        The Covered Person should report the following
pregnancy. All Sicknesses due to the same or a related       inpatient services:
cause are considered One Sickness.                           (a) all inpatient admissions, including length of stay, to
                                                                  a Hospital, convalescent facility, skilled nursing
Skilled Nursing Facility means a lawfully operating               facility, a facility established primarily for the treat-
institution engaged mainly in providing treatment for             ment of substance abuse, or a residential treatment
people convalescing from Injury or Sickness. It must              facility;
have organized facilities for medical services, 24-hour      (b) all inpatient maternity care, after the initial 48/96
nursing service by RNs, a capacity of six or more beds,           hours;
daily medical records for each patient, and a Doctor         (c) all partial hospitalization in a Hospital, residential
available at all times.                                           treatment facility, or facility established primarily
                                                                  for the treatment of substance abuse.
Totally Disabled and Total Disability means Injury or
Sickness which wholly and continuously keeps the             The Covered Person is responsible to fulfill the Pre-
Covered Person, (a) with respect to a student: from          Notification requirement of this plan:
attending classes at the location where he or she is         • Notification of Emergency Hospitalizations: The
enrolled; and (b) with respect to a Dependent, or a            patient, patient’s representative, Doctor or Hospital
student if such classes are not in session, from doing         should telephone 877-795-5430 within 2 working days
those activities that are normal for a person in good          of admission.
health of the same age and sex.
                           10                                                             11
• Pre-Notification of Non-Emergency Hospitalizations:                   CONTINUATION OF COVERAGE
  The patient, Doctor or Hospital should telephone            If the Covered Student becomes ineligible under the
  877-775-5430 at least 3 days prior to the planned           Policy, he or she may continue coverage for himself and
  admission.                                                  his or her covered eligible dependents for up to an addi-
                                                              tional 6 months. Written request for continued coverage
Important: Pre-Notification is NOT a guarantee that           and payment of premium must be made within 31 days of
benefits will be paid.                                        the date the Covered Student became ineligible under the
                                                              Policy. Contact Maksin Management Corp at 1-877-775-
              EXTENSION OF BENEFITS                           5430 for assistance.
If, on the date coverage terminates, a Covered Person is
Totally Disabled as a result of Sickness or Injury and is               COORDINATION OF BENEFITS
receiving treatment for such Sickness or Injury, benefits     Benefits for Accidents and Sickness are coordinated with
will be payable for the Eligible Expenses incurred for        other health insurance the Covered Person may have in
that Sickness or Injury after the date coverage terminates    force as described in the Policy.
until the earliest of the following:
(1) the end of the Sickness or Injury that caused the Total     CERTIFICATE OF CREDITABLE COVERAGE
Disability; (2) the end of the 3 month period following       Coverage under this plan is “Creditable Coverage” under
the date coverage terminated; or (3) the date the applica-    Federal Law. When coverage terminates, the Covered
ble Maximum Amount is reached.                                Person can request a Certificate of Creditable Coverage,
                                                              which is evidence of coverage under this plan. In order to
If a Covered Person is confined to a Hospital on the date     obtain a Certificate of Creditable Coverage, please visit
his or her coverage terminates, charges incurred during       our website at www.maksin.com or contact Maksin
the continuation of that Hospital Confinement shall also      Management Corp at (877) 775-5430.
be included in the term Eligible Expense, but only while
they are incurred during the 31 day period following such                  CONTINUOUSLY INSURED
termination of insurance, subject to the applicable           Continuously insured means a person has been
Maximum Amounts of the Policy.                                continuously insured under the Policy and prior Student
                                                              Health Insurance policies issued to the school. Persons
If the covered Person is receiving treatment for a            who have remained continuously insured will be covered
Sickness or Injury on the date his or her coverage            for conditions first manifesting themselves while
terminates, Eligible Expenses shall include charges           continuously insured except for Expenses payable under
incurred for that Sickness or Injury, but only while they     prior policies in the absence of the current Policy.
are incurred during the 31 day period following such          Previously insured dependents and students must re-
termination of insurance, subject to the applicable           enroll for coverage in order to avoid a break in coverage
Maximum Amounts of the Policy.                                within 30 days of the end of the prior coverage in order
                                                              to maintain coverage for conditions which existed in
In The Event Of Pregnancy. If a Covered Person is             prior Policy Years. Once a break in continuous insurance
pregnant on the date the Policy terminates and the preg-      occurs, the definition of Pre-Existing Condition will
nancy commenced while insured while the Policy was in         apply in determining coverage of any condition which
force, benefits will be payable for Eligible Expenses         existed during such break.
incurred after the Policy terminates until the earliest of:
(a) the date the pregnancy ends; (b) the date the Covered
Person becomes insured under another policy; or (c) the
date the applicable Maximum Amount is reached.

The Extension of Benefits will apply only to the extent
the Covered Person will not be covered under the Policy
or any other health insurance policy in the ensuing term
of coverage.

                            12                                                           13
        BASIC ACCIDENT AND SICKNESS PLAN                                SCHEDULE OF BENEFITS
     (Expenses for Elective Treatment or elective surgery will not be   covered except as specifically provided elsewhere in the Policy.)
Basic Aggregate Maximum per Injury or Sickness per                      $100,000
Policy Year (In-Network and Out-of-Network Combined):
                                                                        In-Network                         Out-of-Network
Deductible Amount per Injury or Sickness per Policy                     $0                                 $100

Out-of-Pocket Limit per Covered Person: This is a                       $2,500                             N/A
benefit that will apply in a Policy Year to a Covered
Person who in that year reaches the Out-of-Pocket Limit.
When this benefit becomes applicable to a Covered
Person during a Policy Year, Covered Percentages under
the Basic Plan are raised. They are raised to 100% for
all Eligible Expenses incurred by the Covered Person in
the remainder of that Policy Year. (Not applicable to

Room and Board Expense, limited to the average semi-                    90% of Allowable Charges 75% of R&C
private room rate
Intensive Care Unit, limited to the intensive care room                 90% of Allowable Charges 75% of R&C
rate for an overnight stay
Hospital Miscellaneous Expense, includes expenses                       90% of Allowable Charges 75% of R&C
incurred for anesthesia and operating room; laboratory
tests and X-rays (including professional fees); oxygen
tent; drugs (excluding take-home drugs), medicines,
dressings; and other Medically Necessary and prescribed
Hospital Expenses.
Pre-Admission Testing                                                   Paid as any other Sickness Paid as any other Sickness
Licensed Nurse (Private Duty Nursing)                                   90% of Allowable Charges 75% of R&C
Physiotherapy                                                           90% of Allowable Charges 75% of R&C
Surgical Expense, when Injury or Sickness requires two                  90% of Allowable Charges 75% of R&C
or more surgical procedures which are performed
through the same approach, and at the same time or
immediate succession, the Company will pay full value
for the most expensive procedure performed and 50% of
the value for the second procedure performed.
Anesthetist (in connection with surgery)                                90% of Allowable Charges 75% of R&C
Assistant Surgeon (in connection with surgery)                          90% of Allowable Charges 75% of R&C
Doctor’s Fees Expense, for non-surgical services of the                 90% of Allowable Charges 75% of R&C
attending Doctor or a consulting Doctor

                                14                                                                       15
Schedule of Benefits, continued                                In-Network                 Out-of-Network
Biologically Based Mental Illness/ Serious Emotional           Paid as any other Sickness Paid as any other Sickness
Mental or Nervous Disorders up to a maximum of 30              90% of Allowable Charges 75% of R&C
days per Policy Year
Alcoholism And Substance Abuse Expense, limited to: (a)        90% of Allowable Charges 75% of R&C
not more than 7 days of active detoxification treatment in
any policy year; and (b) not more than 30 days of in-
patient rehabilitation services in any policy year.

Surgical Expense, when Injury or Sickness requires two         90% of Allowable Charges 75% of R&C
or more surgical procedures which are performed
through the same approach, and at the same time or
immediate succession, the Company will pay full value
for the most expensive procedure performed and 50% of
the value for the second procedure performed.

Anesthetist (in connection with surgery)                       90% of Allowable Charges 75% of R&C

Assistant Surgeon (in connection with surgery)                 90% of Allowable Charges 75% of R&C

Day Surgery Facility/Miscellaneous, when scheduled             90% of Allowable Charges 75% of R&C
surgery is performed in a Hospital or outpatient facility,
including the use of the operating room, laboratory tests
and x-ray examinations (including professional fees),
anesthesia, infusion therapy, drugs or medicines and
supplies, therapeutic services (excluding Physiotherapy
or take home drugs and medicines). Eligible Expenses
must be incurred on the day of surgery or within 48
hours after the surgery.

Hospital Emergency Room, for use of Hospital emergency         100% of Allowable Charges 100% of R&C
room, operating room, laboratory and x-ray examinations,
supplies. A Co-payment Amount of $75 will apply to each
visit unless the Covered Person is admitted to the
Hospital as an inpatient.

Urgent Care Expense, for treatment of an Urgent                90% of Allowable Charges 75% of R&C
Condition by an Urgent Care Provider

Laboratory and X-Ray Examinations                              90% of Allowable Charges 75% of R&C
CAT Scan/MRI                                                   90% of Allowable Charges 75% of R&C
Chlamydia Screening Test Expense, annual screening test        90% of Allowable Charges 75% of R&C
for women who are: under age 20 if they are sexually
active; and at least 20 years old if they have multiple risk
factors; or men who have multiple risk factors.

                            16                                                           17
Schedule of Benefits, continued                              In-Network                  Out-of-Network
Radiation Therapy and Chemotherapy, includes:                Paid as any other Sickness Paid as any other Sickness
anti-nausea drugs used in conjunction with the
chemotherapy, radiation therapy, tests and procedures,
Physiotherapy (for rehabilitation only after surgery), and
Eligible Expenses incurred at a radiological facility;
Eligible Expenses incurred for the administration of
chemotherapy and visits by a health care professional to
administer the chemotherapy.
Tests and Procedures, for diagnostic services and med-       90% of Allowable Charges 75% of R&C
ical procedures performed by the Doctor, other than
Doctor’s visits, physiotherapy, x-rays and lab procedures.
Physiotherapy, up to a maximum of $1,500 per Injury or       90% of Allowable Charges 75% of R&C
Sickness. Benefits are payable when provided by a
licensed physical therapist and only when physical thera-
py begins within 6 months of the onset of symptoms.
Doctor’s Fees Expense, includes injections administered      90% of Allowable Charges 75% of R&C
in the Doctor’s office
Musculoskeletal/Chiropractic Therapy                         Paid as any other Injury   Paid as any other Injury
Consultant’s Fees Expense, when such services are            90% of Allowable Charges 75% of R&C
deemed Medically Necessary and ordered by the attend-
ing Doctor for the purpose of confirming or determining
a diagnosis.
Prescribed Medicines Expense up to a maximum of              100% of R&C after a        No Benefits
$1,500 per Policy Year. Prescriptions must be filled by an   $10 co-payment per
Express Scripts, Inc. participating pharmacy only. A list    generic drug or $30
of nationwide participating pharmacies is available for      co-payment per brand
review at www.express-scripts.com.                           name drug
Biologically Based Mental Illness/ Serious Emotional         Paid as any other Sickness Paid as any other Sickness
Mental or Nervous Disorders up to a maximum of 20            90% of Allowable Charges 75% of R&C
visits per Policy Year
Alcoholism And Substance Abuse Expense:                      90% of Allowable Charges 75% of R&C
(a) up to 60 outpatient visits per Policy Year for the
Covered Person in need of treatment; (b) up to a maxi-
mum of 20 visits per Policy Year for covered family
members, (including visits for remediation through coun-
seling and education), provided that the total number of
such visits, when combined with those of the Covered
Person in need of treatment, does not exceed 60 visits in
any Policy Year; (c) up to a maximum of 5 additional vis-
its for covered family members if a Covered Person in
need of treatment has not received or is not receiving
                            18                                                          19
Schedule of Benefits, continued                                 In-Network                 Out-of-Network
Second Surgical Opinion, when recommended and                   90% of Allowable Charges 75% of R&C
approved by the attending Doctor. Eligible Expenses also
include expenses incurred for required X-rays and diag-
nostic tests done in connection with that consultation.

Ambulance Expense, for the services of a professional           90% of Actual Charges      90% of Actual Charges
ambulance to or from a hospital when required due to
the emergency nature of an Accident or Sickness (not
subject to the deductible)

Prosthetic Devices, includes charges for artificial limbs,      90% of Allowable Charges 75% of R&C
or eyes, and other non-dental prosthetic devices, as a
result of Injury or Sickness. It does not include: eye
exams, eyeglasses, vision aids, hearing aids, communi-
cation aids, and orthopedic shoes, foot orthotics, or
other devices to support the feet.

Durable Medical Equipment and Orthopedic Appliance              90% of Allowable Charges 75% of R&C
Dental Expense:
for Injury to sound natural teeth up to a maximum of            100% of Actual Charges     100% of Actual Charges
$200 per Accident; or for removal of one or more impact-
ed wisdom teeth up to a maximum of $50 per tooth

Temporomandibular Joint Dysfunction (TMJ) Expense,              Paid as any other Sickness Paid as any other Sickness
for non-surgical treatment of TMJ when the TMJ is
medical in origin.

Dermatological Expense, for the diagnosis and treatment         Paid as any other Sickness Paid as any other Sickness
of skin disorders, excluding laboratory fees. Related lab-
oratory expenses are covered under Laboratory and X-
ray Examinations. Eligible Expenses do not include treat-
ment for cosmetic treatment and procedures.

Allergy Testing and Treatment, includes laboratory tests,       Paid as any other Sickness Paid as any other Sickness
Doctor’s visits (including visits to administer injections),
prescribed medications for testing of the allergy (includ-
ing any equipment used in the administration of pre-
scribed medication), and other Medically Necessary
supplies and services.

Diagnostic Testing for Attention Deficit Disorders and          90% of Allowable Charges 75% of R&C
Learning Disabilities, benefits include diagnostic testing
for: (a) attention deficit disorder; or (b) attention deficit
hyperactive disorder; or (c) dyslexia. Once a Covered
Person has been diagnosed with one of these conditions,
medical treatment will be payable as detailed under the
outpatient treatment of Mental and Nervous Disorders
coverage portion of the Policy.

                             20                                                           21
Schedule of Benefits, continued                               In-Network                    Out-of-Network
Acupuncture In Lieu of Anesthesia Expense, when               90% of Allowable Charges 75% of R&C
acupuncture is used in lieu of other anesthesia, for a
covered surgical or dental procedure.

Maternity, including well newborn nursery care, for a         Paid as any other Sickness Paid as any other Sickness
minimum of 48 hours after a vaginal delivery and for a
minimum of 96 hours after a cesarean delivery. Pre-
notification is recommended after the 48/96 hours.

Transfusion or Dialysis of Blood Expense, benefits            90% of Allowable Charges 75% of R&C
include the cost of: whole blood, blood components, and
the administration thereof.

Skilled Nursing Facility Expense (pre-notification recom-     90% of Allowable Charges 75% of R&C
mended), for treatment rendered (a) in lieu of a hospital
confinement; or (b) within 24 hours following a hospital
confinement and for the same or related cause(s) as
such hospital confinement.

Rehabilitation Facility Expense (pre-notification recom-      90% of Allowable Charges 75% of R&C
mended). Confinement must follow within 24 hours of and
be for the same or related cause(s) as a period of hospital
confinement or Skilled Nursing Facility confinement.

Hospice Expense (pre-notification recommended)                90% of Allowable Charges 75% of R&C

Intercollegiate Sports Injury, up to $500 per Accident        Paid as any other Injury      Paid as any other Injury

Accidental Death and Dismemberment Principal Sum                                         $10,000

PLAN (Student Only)
If elected by the Covered Student during initial enrollment
and the appropriate premium is paid, the Optional
Supplemental Accident and Sickness Plan will increase
the Aggregate Maximum per Injury or Sickness per
Policy Year from $100,000 per Injury or Sickness per
Policy Year to $300,000 per Injury or Sickness per Policy
Year. The combined maximum benefit payable for Basic
Accident and Sickness Plan and Optional Supplemental
Accident and Sickness Plan is $300,000 per Injury or
Sickness per Policy Year.

Not available to early arrival students for the summer
semester; may be purchased the following fall semester.

                            22                                                             23
                       EXCLUSIONS                                    teeth within 12 months of the accident and except for
The Policy does not cover nor provide benefits for                   dental care or treatment necessary due to congenital
Accident, Sickness, or treatment of a medical condition              disease or anomaly.
arising out of:                                                   7. eyeglasses, hearing aids, and examination for the
 1. pregnancy, except as specifically provided under the             prescription or fitting thereof.
     Policy.                                                      8. rest cures, custodial care and transportation.
 2. illness, accident, treatment or medical condition aris-
     ing out of:                                                              PRE-EXISTING CONDITIONS
     a) war or act of war (whether declared or unde-             (Applicable to persons enrolling on a voluntary basis only)
         clared); participation in a felony, riot or insurrec-   Pre-existing Conditions are not covered for the first 12
         tion; service in the Armed Forces or units auxil-       months following a Covered Person’s effective date of
         iary thereto; and                                       coverage under the Policy. This limitation will not apply
     b) aviation, other than as a fare-paying passenger on       if the individual seeking coverage under the Policy has an
         a scheduled or charter flight operated by a sched-      aggregate of 12 months of prior Creditable Coverage and
         uled airline.                                           becomes eligible and applies for coverage under the
 3. cosmetic surgery, except that cosmetic surgery shall         Policy within 63 days of termination of prior Creditable
     not include reconstructive surgery when such service        Coverage. Credit will be given for the time the individual
     is incidental to or follows surgery resulting from          was covered under the prior Creditable Coverage.
     trauma, infection or other diseases of the involved
     part, and reconstructive surgery because of congeni-        The Pre-existing Conditions limitation does not apply to:
     tal disease or anomaly of a covered Dependent child         (a) a newborn dependent child; or (b) a child adopted by
     which has resulted in a functional defect. However,         the Covered Person or placed with the Covered Person
     if the policy provides hospital, surgical or medical        for adoption, if adoption or placement for adoption
     expense coverage, this exclusion shall not apply with       occurs while covered under the Policy; or (c) pregnancy
     respect to cosmetic surgery determined, as a result of      that begins 10 months from the Covered Person’s effec-
     utilization review and External Review, to be               tive date of coverage under the Policy, subject to a cred-
     Medically Necessary.                                        it for previous Creditable Coverage.
 4. care in connection with the detection and correction
     by manual or mechanical means of structural imbal-          Credit For Prior Coverage: A Covered Person whose
     ance, distortion or subluxation in the human body for       coverage under prior Creditable Coverage ended no more
     purposes of removing nerve interference and the             than 63 days before the Covered Person’s effective date
     effects thereof, where such interference is the result      under the Policy, will have any applicable Pre-Existing
     of or related to distortion, misalignment or subluxa-       Condition limitation reduced by the total number of days
     tion of or in the vertebral column. This exclusion          the Covered Person was covered by such coverage. If
     shall not apply if coverage of Doctor’s services in         there was a break in Creditable Coverage of more than 63
     the Doctor’s office are provided under the Policy.          days, the Company will credit only the days of such cov-
 5. treatment provided in a government hospital; bene-           erage after the break.
     fits provided under Medicare or other governmental          Creditable Coverage means coverage under any of the
     program (except Medicaid), any state or Federal             following:
     workers’ compensation, employers’ liability or occu-        (a) a group health plan;
     pational disease law; benefits to the extent provided       (b) health insurance coverage;
     for any loss or portion thereof for which mandatory         (c) Part A or B of Title XVIII the Social Security Act;
     automobile no-fault benefits are recovered or recov-        (d) Title XIX of the Social Security Act, other than cov-
     erable; services rendered and separately billed by               erage consisting solely of benefits under section
     employees of hospitals, laboratories or other institu-           1928;
     tions; services performed by a member of the cov-           (e) Chapter 55 of Title 10, United States Code;
     ered person’s immediate family; and services for            (f) a medical care program of the Indian Health Service
     which no charge is normally made.                                or of a tribal organization;
 6. dental care or treatment, except for such care or            (g) a state health benefits risk pool;
     treatment due to accidental Injury to sound natural         (h) a health plan offered under chapter 89 of Title 5,
                                                                      United States Code;
                             24                                                              25
(i) a public health plan (as defined in regulations);                         TRAVEL GUARD
(j) a health benefit plan under section 5(e) of the Peace    TRAVEL ASSIST AND STUDENT ASSIST SERVICES
    Corps Act (22 U.S.C. 2504(e) ).
                                                            Procedures on How to Access Travel Guard’s 24-hour
               MANDATED BENEFITS                            Assistance Call Center
                                                            How to Contact Travel Guard:
Coverage for the following benefits to be paid as any       • Inside the US and Canada, dial 1-877-249-5362 toll-
other Sickness except under certain coverages wherein         free.
there are internal limits: Biologically based Mental        • Outside the US and Canada:
Illness/Serious Emotional Disturbances and Mental and       • Request an international operator.
Nervous Disorders; Breast Cancer Treatment; Breast          • Ask the international operator to connect to an AT&T
Reconstruction; Clinical Trials Expense; Outpatient           operator.
Chemical Abuse and Chemical Dependence;                     • Request the AT&T operator to place a collect call to the
Mammographic Examination; Cytologic Screening;                USA at 1-715-295-9625.
Cancer Second Opinion; Diagnostic Screening for             • Our fax number is 1-713-974-3422.
Prostate Cancer; Diabetes Treatment; End of Life Care;
Pre-Hospital Medical Emergency Services; Bone               When to Contact Travel Guard:
Mineral Density Measurements and Tests; Medical             • Call Travel Guard when you require medical assistance
Foods; and Contraceptive Services.                            or have a medical emergency.
                                                            • Call Travel Guard for all non-medical situations (lost
In addition to the above benefits, the following benefits     luggage, lost documents, legal help, etc.).
are applicable to Covered Students attending the            • Call Travel Guard whenever there is a question.
Hartford, CT campus: Autism Spectrum Disorders; Early
Intervention Services; Hearing Aids for Children;           Travel Guard is available 24-hours-a-day/7-days-a-
Craniofacial Disorders; Blood Lead Screening; Acci-         week/365-days-a-year.
dental Ingestion of Controlled Drugs; Hypodermic            Our multi-lingual/multi-cultural Travel Assistance
Needles or Syringes; Prescribed Drugs for Cancer;           Coordinators (TACs) are trained professionals ready to
Inherited Metabolic Disease Treatment; Lyme Disease         help you should the need arise while you are traveling or
Treatment; Pain Management; Ostomy Appliances and           away from home. The Travel Assist Services Medical
Supplies; Colorectal Cancer Screening; Neuro-               Staff consists of fulltime, on-site Registered Nurses and
psychological Testing; Epidermolysis Bullosa Treatment;     Emergency Physicians who work as a team to provide the
Home Health Care; Occupational Therapy; Emergency           best outcome for our clients. This team is directed by a
Ambulance; Surgical Removal of Tumors and Treatment         dedicated Medical Director (MD) and Manager of
of Leukemia; Cancer Clinical Trials; Infertility            Medical Services (RN). Nursing staff is on-site 24-
Treatment; Isolation Care and Emergency Services; and       hours; a physician has daily responsibility for a 24-hour
Medical Complications of Alcoholism. Please see the         period and is onsite during daytime hours.
Policy on file with the University for complete details
and any other applicable mandates.                          What information will you need to provide to Travel
                                                            Guard when you call:
                                                            • Advise Travel Guard who you are insured by.
                                                            • Provide your Underwriter Reference number.
                                                            • Advise Travel Guard regarding the nature of your call
                                                              and/or emergency. Be sure to provide your contact
                                                              information at your current location in the event Travel
                                                              Guard needs to call you back.

                                                                            Description of Services
                                                            Information/General: These services include advice and
                                                            information regarding travel documentation, immuniza-
                                                            tion requirements, political/ environmental warnings, and
                                                            information on global weather conditions. Travel Guard
                                                            can also provide information on available currency
                           26                                                          27
exchange rates, local Bank/Government holidays, and,
by implementing our databases with the information,                     Repatriation of Mortal Remains/
provide ATM and Customer Service locations to clients.                         Medical Evacuation
Travel Guard also provides emergency message storage           (Benefits provided by National Union Fire Insurance
& relay and translation services.                                          Company of Pittsburgh, PA)
• Visa & Immunization
                                                               Repatriation of Mortal Remains: In the event an
• Weather & Exchange Rates
                                                               Injury or Sickness causes death while the Covered
• Environmental & Political Warnings
                                                               Person is outside a 100 mile radius from his or her
                                                               current place of primary residence, the Company will
Technical: These services provide assistance to members
                                                               reimburse covered expenses incurred for preparation
in the event of lost or stolen luggage, personal effects,
                                                               and transportation of the body remains.
documents and tickets. Travel Guard can arrange cash
transfers & vehicle return in the event of illness or acci-    Medical Evacuation: The Policy will pay for evacu-
dent, provide legal referrals, and help with arrangements      ation to the nearest adequate medical facility follow-
for members who encounter en-route emergencies that            ing a covered Injury or Sickness if the Covered Person
force them to interrupt their trips.                           is outside a 100 mile radius from his or her current
• Legal Referral                                               place of primary residence and his or her Doctor
• Embassy/Consulate Information                                determines that adequate medical treatment is not
• Lost/Stolen Luggage & Personal Effects                       locally available.
• Assistance
• Lost Document Assistance                                     Combined Maximum Limit of $1,000,000
• Cash Transfer Assistance                                     Travel Guard must make all arrangements and must
• En-route Travel Assistance                                   authorize all expenses in advance for these benefits to
• Claims-related Assistance                                    be payable. If it is not reasonably possible to contact
• Telephone Interpretation                                     Travel Guard in advance, the Company reserves the
                                                               right to determine the benefits payable, including any
Medical: These services are the most complicated of            reductions.
those offered and can last up to several weeks. They
involve Travel Guard’s Medical Staff in addition to other
network providers and often include post-case pay-                       STUDENT ASSIST SERVICES
ment/billing coordination on the traveler’s behalf. These
services include physician/dental/hospital referral, med-     Concierge Services: You receive the comforts, care, and
ical case monitoring, shipment of medical records and         attention of Student Assist’s Personal Assistance
prescription medications, medical evacuation, repatria-       Coordinators available 24/7 to respond to virtually any
tion of remains, and insurance/claims coordination.           request – large or small.
                                                              Personal Security Assistance: You can feel safe and
Medical Assistance:                                           secure with Travel Guard’s Personal Security Assistance
• Medical Referral                                            at home or while traveling. To activate personal security
• Out-patient Assistance                                      services, please log on to:
• In-patient Assistance                                                 www.chartisinsurance.com/us/security.
                                                              For initial setup, your login is “9499769” and the pass-
Medical Transport:                                            word is “security.”
• Medical Evacuation                                              For more details visit www.maksin.com/RPI.aspx
• Repatriation of Mortal Remains

                            28                                                           29
       AMERICAN HEALTH HOLDING, INC.                                        CLAIM FILING PROCEDURES
        24-HOUR STUDENT EMERGENCY                              Claim forms can be accepted directly from Doctors or
                   CARE HOTLINE                                facilities if the form includes the name of the Covered
    (American Health Holding, Inc. is not affiliated           Person, Covered Student’s school name, identification
     with National Union Fire Insurance Company                number, date of services, diagnosis, treatment procedure
                   of Pittsburgh, Pa.)                         and billed charges. Proof of loss must be furnished with-
For confidential health care advice and information, 24        in 90 days after the date of such loss.
hours a day, 365 days a year, call toll-free (866) 315-8756.
                                                               A Company claim form may be secured by logging onto
Comprehensive Resources and Advice from                        www.maksin.com/RPI.aspx. Complete and sign the
Registered Nurses                                              claim form and mail with itemized hospital and/or med-
• Direct access to an extensive Health Information             ical bills to the Claim Office at the following address:
Library, covering issues ranging from women’s health to
pediatrics. Detailed directories with topic codes and                        Maksin Management Corp
instructions for access to health-related topics.                                   P.O. Box 2647
• Choose to talk directly with a nurse. Discuss a current                     Camden, NJ 08101-2647
illness or health issue, or receive counseling on chronic                     Toll Free: (877) 775-5430
conditions. Nurses can also educate callers about treat-
ments, lifestyle choices and self-care strategies.             Only one claim form is required per Injury or Sickness.
• Integrated phone access to specially trained personnel,      After filing the initial claim form, additional bills may be
trained to provide referral services for a number of health    forwarded with name, identification number and school
related concerns including mental health and/or sub-           name/policy number.
stance abuse.                                                  Questions regarding enrollment and payment or waiver,
                                                               benefits, eligibility, claims procedures or claims status
                 AMACORE VISION                                should be directed to:
        A Product of The Amacore Group, Inc.
       (The Amacore Group, Inc. is not affiliated                            Maksin Management Corp
     with National Union Fire Insurance Company                                     P.O. Box 2647
                   of Pittsburgh, Pa.)                                        Camden, NJ 08101-2647
Amacore Vision is one of the nation’s largest cost share                      Toll Free: (877) 775-5430
vision networks with thousands of eye care professionals                        Local Servicing Agent
including Optometrists, Opticians and optical outlets in                       Austin & Company, Inc.
thousands of locations nationwide. It is the only national                  20 Corporate Woods Boulevard
network that includes Ophthalmologists who discount all                        Albany, NY 12211-2350
of their services on medical and surgical procedures,                               518-465-3591
including cosmetic surgery and LASIK. Amacore Vision
also provides substantial discounts on all contact lenses,     At Maksin Management Corp, we value the trust our
frames and designer sunglasses.                                customers have placed in us. That is why protecting
Member Instructions                                            the privacy of your personal information is of para-
• Before scheduling your vision appointment, please            mount importance to us. For more information,
verify provider participation by calling 1-800-354-8336.       please go to our website at www.maksin.com.
• Be sure to present your membership card and identify
yourself as a valid Amacore Vision member before your          It is the Covered Person’s responsibility to maintain
exam.                                                          continuity of coverage by inquiring about such coverage
                                                               if he or she has not received the information for the new
Visit RPI’s webpage at www.maksin.com/RPI.aspx to              Policy Year.
learn about additional money-saving discount programs
offered to you under the Plan. (These services and prod-
ucts are not insurance. They are comprised of indepen-
dent vendors not affiliated with National Union Fire
Insurance Company of Pittsburgh, Pa.)
                            30                                                             31
The insurance described in this brochure provides
limited benefits only. It does not provide basic hospital,
basic medical or major medical insurance as defined by
the New York State Insurance Department.

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