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Incoming Schedule of Coverages
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Benefits
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Coverage
Click here
for definitions and answers to frequently asked
questions. |
Plan "S"
$100,000
No Maternity
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Plan "AB"
$100,000
With Maternity
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Plan "CD"
$250,000
With Maternity
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Plan "E"
$100,000
No Maternity |
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Eligibility
Student/Scholar
Requirement: Undergraduate
or Graduate Students/Scholars holding a J1 or F1 visa, who are traveling to the United
States and currently are enrolled in an accredited
institution of higher learning on a full-time basis with
no less than 6 credit hours, unless the institution’s
full-time status requires less credit hours. No
such requirement applies for Spouse, Children or
Visitors.
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Students/
Scholars
(age 17-26) |
Students/Scholars/
Spouses/Children
(age 0-69) |
Students/Scholars/
Spouses/Children
(age 0-69) |
Students/Scholars
Spouses/Children/
Visitors (age 0-69)
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Deductible |
$100
Annually |
$100
Per Occurrence |
$250
Per Occurrence |
$100
Annually
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Benefit
A
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Medical Expenses (UCR)
for injury or illness occurring during the Period of
Coverage.
The Plan does not cover routine office
visits, routine vaccinations or pre-existing conditions.
Initial
treatment of an injury must occur within 60
days of the accident or during the period of
coverage, whichever is earlier.
Illness must first manifest itself during the
period of coverage.
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$100,000 |
$100,000
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$250,000
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$100,000 |
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Medical Evacuation |
$50,000 |
$50,000 |
$50,000 |
$50,000 |
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Prescription Drugs
80% of UCR |
$1,000
(Max
per 12 months of coverage) |
$1,000
(Max per policy period)
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$1,000
(Max per policy period) |
$1,000
(Max per policy period) |
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Dental Treatment
80%
of the Usual,
Customary and Reasonable (UCR) charge
to a maximum of $1,000 per policy year
as a result of injury to to natural teeth caused by an
accident.
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$1,000
(Max per 12
months of coverage) |
$1,000
(Max per policy period) |
$1,000
(Max per policy period) |
$1,000
(Max per policy period) |
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Physiotherapy
Accident only, when prescribed by the attending
physician, limited to one visit per day,
$25 per visit, to a maximum of $500 per policy year
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$500 |
$500 |
$500 |
$500 |
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Psychotherapy
The treatment of mental disorders, nervous disorders,
alcoholism, and drug addiction, up to $30 per visit, one
visit per day, to a maximum of 10 visits per policy year
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Maximum of 10 visits |
$5,000
(Max per policy year) |
$5,000
(Max per policy year) |
$5,000
(Max per policy year) |
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Organ transplant,
bone marrow transplant, skin grafts, kidney dialysis or
similar treatments limited to $10,000 all UCR charges
combined per policy year. |
$10,000
(UCR
per 12 months of coverage) |
$10,000 |
$10,000 |
$10,000 |
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Surgery: Physician fees for a surgical procedure to a $5,000
maximum per policy year |
$5,000
maximum per policy year |
$5,000
maximum per policy year |
$5,000
maximum per policy year |
$5,000
maximum per policy year |
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Anesthetist
Services |
30%
of the UCR charges of surgical allowance |
30%
of the UCR charges of surgical allowance |
30%
of the UCR charges of surgical allowance |
30%
of the UCR charges of surgical allowance |
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Outpatient
Day Surgery Miscellaneous Expenses when surgery is
performed in a hospital emergency room, trauma center,
physician's office, outpatient surgical center or
clinic, for covered services and supplies, all charges
combined to a maximum of $1,500 per day. |
Maximum
of $1,500 per day |
Maximum of $1,500 per
day |
Maximum of $1,500 per
day |
Maximum of $1,500 per
day |
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Outpatient
Miscellaneous Expenses - including medical emergency
room expenses, diagnostic X-ray and laboratory
expenses, MRIs, CAT Scans, Ultrasound, Amniocentesis,
AFP Screening and Fetal Stress/Non Stress Tests, or
similar procedures, when prescribed by the attending
physician, to a $1,000 maximum per policy year.
Fertility testing is excluded and not a covered
expense. |
$1,000 maximum per policy
year |
$1,000 maximum per policy
year |
$1,000 maximum per policy
year |
$1,000 maximum per policy
year |
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In-Patient
Hospital
miscellaneous
Expenses
for covered services and
supplies, all UCR charges combined to a maximum of
$1,500 per day. |
Maximum
of $1,500 per day |
Maximum of
$1,500 per day |
Maximum of
$1,500 per day |
Maximum of
$1,500 per day |
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Ambulance
Service, for transportation to or from a hospital,
$400 per trip maximum |
$400 per trip maximum |
$400 per trip maximum |
$400 per trip maximum |
$400 per trip maximum |
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Motor
Vehicle Accidents, excess to the motor vehicle
insurance to a maximum of $2,000 per policy year |
Maximum
$2,000 per policy year |
Maximum of $2,000 per policy year |
Maximum of $2,000 per policy year |
Maximum of $2,000 per policy year |
| Benefit
B
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Accidental
Death & Dismemberment
(AD&D) |
$15,000
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$15,000
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$15,000
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$15,000 |
| Benefit
C
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Repatriation of Remains
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$10,000 |
$10,000 |
$10,000
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$10,000 |
| Benefit D |
Pregnancy/
Childbirth/ Miscarriage
Maximum
of $5,000 per policy year.
Benefits are only available if the enrollment has
occurred at least 30 days prior to conception.
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No maternity option
available for Plan S |
$5,000
(maximum benefits) |
$5,000
(maximum benefits) |
No maternity option
available for Plan E. |
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Cancellation Policy
All premiums are fully earned
upon Application, and are Non-Refundable. Please apply
only for the term of coverage you need, and re-apply
as often as necessary as your plans may change.
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What
is Covered?
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MEDICAL
BENEFITS - ACCIDENT AND SICKNESS
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Charges
made by a hospital for room and board, floor
nursing and other services exclusive of charges
for professional service and with the exception of
personal services of a non-medical nature;
provided, however, that expenses do not exceed the
hospital's average charge for semiprivate room and
board accommodation or intensive care when
medically necessary.
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Charges
made for diagnosis, treatment and surgery by a
physician.
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Charges
made for the cost and administration of
anesthetics.
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Charges
for medication, x-ray services, laboratory tests
and services, the use of radium and radioactive
isotopes, oxygen, blood transfusion, iron lungs,
and medical treatment.
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Charges
for physiotherapy, if recommended by a physician
for the treatment of a specific disablement and
administered by a licensed physiotherapist.
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Dressings,
drugs, and medicines that can only be obtained
upon a written prescription of a physician.
The
charges enumerated above shall in no event include
any amount of such charges which are in excess of
regular and customary charges.
A charge incurred by an Insured Person
shall be deemed a regular and customary charge for
the services and supplies for which the charge is
made if it is not in excess of the average charge
for such services and supplies in the locality
where received, considering the nature and
severity of the sickness of bodily injury in
connection with which such services and supplies
are received.
If the charge incurred is in excess of such
average charge, such excess amount shall not be
recognized as covered expenses.
All charges shall be deemed to be incurred
on the date such services or supplies which give
rise to the expense or charge are rendered or
obtained.
Usual,
Customary and Reasonable Charge (UCR)
means the payment amount, as determined by the
Company, for services rendered by a professional
provider.
The Company (AIG) reserves the right of final
determination of the amount payable for any service or
supply.
The
following is the basis for determination of UCR:
Usual
- an amount a professional provider usually charged
for a given service.
Customary
– an amount which falls within the range of charges
for a given service billed by most professional
providers in the same locality who have similar
training and experience.
Reasonable
– am amount which is usual and customary or which
would not be considered excessive in a particular case
because of unusual circumstances.
If
the charge is in excess of UCR, no payment will be
made with respect to the excess, and the excess will
not qualify as a Covered Expense under the Policy.
For
the purpose of this section, only such expenses,
incurred as the result of and within 26
weeks of a disablement, which are specifically
enumerated in the following list of charges, and which
are not excluded in Exclusions, shall be considered as
covered expenses.
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Emergency Medical Evacuation |
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Emergency Medical Evacuation provides up to
$50,000. for transportation of an Insured
Person from a location having inadequate medical
facilities to treat the Insured's condition to a
facility which does.
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Repatriation of Remains |
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to $10,000. will be paid for the return of the remains of any
Insured Person to the country of domicile in the event
the Insured Person dies while this policy is in
effect. |
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NOTE:
This is only a brief description of the
benefits of this Plan and does not cover all the
terms, conditions and limitations.
The Policy shall provide the only basis for
coverage and claim.
If there is any conflict between this
description and the Policy, the Policy will govern in
all cases.
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To
learn more about what is not covered, please
Click
Here
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A
Special Note to Seniors
*
These
rates are for persons traveling abroad and their
family members traveling with them, 69 years of age.
Additional coverage is available for persons 70-80
years of age. Please call
1-800-247-5575 for premium rates or Click
Here for additional program options.
Underwritten
by the Insurance Company of the State of Pennsylvania,
a member of the company of the AIU Holdings,
rated A "Excellent" by A.M. Best
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Incoming
to the USA Forms and Applications:
Apply
Online or by Phone or Fax
Incoming Application -
(.pdf
format)
Click Here for Premium
Information
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