Excess Accident Medical Expense Benefit

Pays 100% of usual and customary expenses up to $25,000 less a deductible, if chosen by you, for excess medical or surgical treatment, hospital confinement and services of a trained nurse for treatment commencing within 90 days of the date of accident and incurred within two years of the accident date.

The cost of treatment for injury to natural teeth, incurred within two years from the date of accident, is included.

In no event will payment exceed the $25,000 Maximum Benefit Amount for the aggregate of all such medical, surgical, hospital, nurse and dental expenses incurred as the result of any one accident.

Benefits will be paid only for that portion of actual expenses incurred for any covered loss sustained by the insured by reason of injury, which is in excess of all other compensation paid or payable to the insured, or on the insured’s behalf by or under another Health Care Plan (as defined), hospital or surgical plan, third party liability, or automobile medical payments.

You also have the option to add a “primary benefit” to the Excess Accident Medical Expense Benefit described above. The primary benefit pays for the first $200 or $500 of eligible expenses incurred, depending on which benefit amount you choose, without regard to other insurance. Thereafter, benefits are payable for eligible expenses that are not recoverable from another Health Care Plan, not to exceed the $25,000 Maximum Benefit Amount.

Additional Benefits Automatically Included with Your Accident Medical Expense Plan

Accidental Death & Dismemberment

If within one year from date of accident, covered injuries result in death, dismemberment or loss of sight, the following benefit will be paid.

Loss of:

“Loss” means with regard to hands and feet, complete severance through or above the wrist or ankle joint; with reference to sight, the total, permanent loss of sight of the eye. The loss of sight must be irrecoverable by natural, surgical or artificial means. “Severance” means the complete separation and dismemberment of the part from the body. Only one amount, the largest to which the insured is entitled, is payable for all injuries resulting from one accident. This benefit is paid in addition to any medical expense benefits.

Medical Evacuation Benefit

If, while traveling outside of the insured’s home country, a doctor determines that an emergency evacuation is required for appropriate medical treatment to be provided for a covered injury, benefits will be paid for the usual and customary expenses incurred, not to exceed the maximum benefit amount of $10,000.

Benefits will be provided for: 1) medical services required for evacuation to the nearest adequate medical facility; 2) escort services, if the covered person is disabled, upon the recommendation of the insured’s doctor; 3) ambulance service to the nearest airport and air ambulance upon departure; 4) air transportation costs to return the covered person to the insured’s home country, including a stretcher, oxygen or other special medical arrangements if the insured’s doctor states in writing that such services are medically necessary; and 5) expenses above the cost of a return airfare ticket held by the covered person, or in the absence of a ticket, the cost of an economy airfare ticket.

Repatriation Benefit

If, while traveling outside the insured’s home country, the insured should die from a covered injury, benefits will be paid for the usual and customary expenses incurred for the preparation and transportation of the body to his home country, not to exceed a maximum benefit of $10,000. All expenses must be approved by the Plan Administrator before the body is prepared for transportation.

OPTIONAL CATASTROPHIC PLANS

$1,000,000 Catastrophic Accident

Medical Expense Benefit

A School may elect additional coverage in the form of a Catastrophic Plan. This supplemental plan includes a Maximum Medical benefit of $1,000,000 with a lifetime benefit period. A $25,000 deductible applies which must be satisfied by expenses paid under the base plan, paid by other insured plans, or paid by the insured within the 24 month period immediately following the accident. The first eligible expense must be incurred within 26 weeks of the date of the covered accident.

$500,000 Catastrophic Cash

Benefit for Total Disability

A School may also elect to add Catastrophic Cash Benefits. This plan will pay a maximum benefit of up to $500,000 beginning with a lump sum benefit amount of $100,000, if a covered accident results in paralysis,* coma or brain death, and any of these conditions continue for six consecutive months. As long as total paralysis, coma or brain death continues, subsequent benefit amounts of $40,000 per year will be paid until the maximum benefit amount is reached. Paralysis, coma or brain death must occur within 180 days from the date of the accident and continue for a period of six consecutive months. The annual benefit amounts will not exceed ten years in duration. This benefit is payable in addition to the Accident Medical Expense Benefit.

* Full benefits are payable for paralysis of two or more limbs. Benefits are reduced by 50% for paralysis of one limb.

This K-12 School Accident Issurance Does Not Cover:

Intentionally self-inflicted injury, suicide or any attempt thereat while sane or insane; commission or attempt to commit a felony or an assault; commission of or active participation in a riot or insurrection; bungee-cord jumping, parachuting, skydiving, parasailing, hang-gliding, snowboarding, skateboarding, motorcycle racing, racing rocket-powered, jet propelled or nuclear-powered vehicles; declared or undeclared war or act of war; flight in, boarding or alighting from an aircraft, except as a fare-paying passenger on a regularly scheduled commercial airline; travel in or on any on-road and off-road motorized vehicle that does not require licensing as a motor vehicle; participation in any motorized race or contest of speed; an accident if the covered person is the operator of a motor vehicle and does not possess a valid motor vehicle operator’s license, unless the covered person holds a valid learners permit and the covered person is receiving instruction from a driver’s education instructor; sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof, except for any bacterial infection resulting from an accidental external cut or wound or accidental ingestion of contaminated food; release of nuclear energy or radiation, including sickness or disease resulting from such release; the covered person being legally intoxicated as determined according to the laws of the jurisdiction in which the covered accident occurred; voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a physician and taken in accordance with the prescribed dosage; injuries compensable under workers’ compensation law or any similar law; occupational injuries for which benefits are not paid under the workers’  compensation law or any similar law; a cardiovascular accident or stroke resulting, directly and independently of all other causes, from exertion, as verified by a physician, while the covered person participates in a covered activity; operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it. For purposes of this exclusion, under the influence of alcohol, means intoxicated, as defined by the law of the state in which the covered accident occurred. In addition, benefits will not be paid for services or treatment rendered by any person who is employed or retained by the policyholder or living in the covered person’s household or provided by a parent, sibling, spouse or child of either the covered person or the covered person’s spouse; an injury resulting from participation in or practice in Interscholastic Sports, including travel to and from games and practice, unless specifically provided for in the policy.

Accident Medical Limitations and Excluded Expenses:

Cosmetic surgery, except for reconstructive surgery needed as the result of a covered injury; any elective or routine treatment, surgery, health treatment, or examination, including any service, treatment or supplies that are deemed by us to be experimental or investigational and are not recognized and generally accepted medical practice in the United States; blood, blood plasma, or blood storage, except expenses by a hospital for processing or administration of blood; treatment in any Veteran’s Administration, federal, or state facility, unless there is a legal obligation to pay; services or treatment provided by persons who do not normally charge for their services, unless there is a legal obligation to pay; rest cures or custodial care; initial eyeglasses, contact lenses or hearing aids; repair or replacement of existing dentures, partial dentures, braces or bridgework; personal services such as television and telephone or transportation; orthopedic appliances used mainly to protect an injury so that the covered person can take part in interscholastic sports; expenses payable by any automobile insurance policy without regard to fault; services or treatment provided by an infirmary operated by the policyholder; treatment of injuries that result over a period of time (such as blisters, tennis elbow, etc.), and that are a normal, foreseeable result of participation in the covered activity; treatment or service provided by a private duty nurse; repair or replacement of existing artificial limbs, eyes and larynx; treatment of hernia of any kind; charges for any article of clothing intended for use more than once.

Terms of Coverage:

Benefits are payable for injuries which result directly and independently of all other causes, from a covered accident, while coverage is in effect, up to the plan maximum. The first eligible medical expense must be incurred within 90 days of the date of the covered accident. Two year benefit period available on all plans.

Effective Date—Coverage becomes effective on the date requested provided the premium and the enrollment form are received and accepted by the Life Insurance Company of North America (a CIGNA company) or its agent.

General Definitions:

Accident—A sudden, unforeseeable external event which causes injury to one or more insureds and occurs during a covered activity while coverage is in effect. (In Missouri, Accident means a sudden, unforeseeable event which causes injury to one or more insureds and occurs during a covered activity while coverage is in effect.)

Health Care Plan—Any contract, policy, or other arrangement, whether individually purchased or incidental to employment or membership in an association or other group, which provides benefits or services for health care, dental care, disability benefits or repatriation of remains. A Health Care Plan includes group, blanket, franchise, family or individual policies; subscriber contracts; uninsured agreements or arrangements; coverage provided through Health Maintenance Organizations, Preferred Provider Organizations and other prepayment, group practice and individual practice plans; medical benefits provided under automobile “fault” and “no-fault” – type contracts; medical benefits provided by any governmental plan or coverage or other benefit law, except a state-sponsored Medicaid plan; or a plan or law providing benefits only in excess of any private or non-governmental plan; other valid and collectible medical or health care benefits or services.

Injury—Bodily harm which results, directly and independently of all other causes, from an accident. All injuries sustained in one accident, including all related conditions and recurring symptoms of the injuries will be considered one injury. (In Florida, Injury means bodily harm from an accident which is the direct cause, independent of disease or bodily infirmity, of the covered loss.)

School Travel—Transportation on a school bus or private passenger automobile driven by a member of the faculty or staff of the school, a parent of the covered person, or other adult with a valid drivers’ license whom the school has specifically designated to transport covered persons to a school supervised and sponsored activity.

Usual and Customary—All benefits will be based on the normal charge, in the absence of insurance, made by the provider of a necessary supply or service, but not more than the prevailing charge in the area for like services by a provider with similar training or experience; or for a supply that is identical or substantially equivalent. Where appropriate, Usual and Customary Charge will be based on a relative value schedule appropriate to the area and type of service provided.

Other insurance programs are available upon request.