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Certified Period Maximum (including all benefits) | $300,000 (Participant) $50,000 (Spouse) $50,000 (Child) | $250,000 (Participant) $50,000 (Spouse) $50,000 (Child)
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| Maximum Benefit per Injury or Illness | $300,000 (Participant) $50,000 (Spouse) $50,000 (Child) | $250,000 (Participant) $50,000 (Spouse) $50,000 (Child)
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| Deductibles | $100 per Injury or Illness Reduced to $50 if treatment is from Student Health Center per Certificate Period
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| Coinsurance - Claims incurred in US or Canada | For the Certificate Period, Underwriters will pay 80% of the next $5,000 of Eligible Expenses after the Deductible, then 100% to the Certificate Period Maximum. Coinsurance will be waived if Eligible Expenses are incurred within the PPO or at a Student Health Center | For the Certificate Period, Underwriters will pay 80% of the next $10,000 of Eligible Expenses after the Deductible, then 100% to the Certificate Period Maximum
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| Coinsurance - Claims incurred outside US or Canada | For the Certificate Period, Underwriters will pay 100% of Eligible Expenses after the Deductible up to the Certificate Period Maximum | For the Certificate Period, Underwriters will pay 18% of the next $10,000 of Eligible Expenses after the Deductible, then 100% to the Certificate Period Maximum
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| Hospital Room and Board | Average Semi-private room rate, including nursing services
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| Local Ambulance | $350 per Injury or Illness, when covered Illness or Injury results in Inpatient hospitalization
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| Intensive Care Unit | Usual, Reasonable and Customary charges
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| Hospital Pre-certification Penalty | 50% of Eligible Medical Expenses
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| Outpatient Treatment | Usual, Reasonable and Customary charges
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| Outpatient Prescription Drugs | 50% of Actual Charges
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| Mental Health Disorders | Outpatient: $50 Maximum per day, $500 Maximum Lifetime Inpatient: Usual, Reasonable, and Customary Charges to $10,000 Maximum Lifetime Treatment must not be provided at a Student Health Center
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| Maternity Care for a Covered Pregnancy | Usual, Reasonable and Customary charges
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| Routine Nursery Care of Newborn | $750 Maximum per Certificate Period | $250 Maximum per Certificate Period
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| Therapeutic Termination of Pregnancy | $500 Maximum per Certificate Period
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| Physical Therapy & Chiropractic Care | Maximum $50 per visit, per day Must be ordered in advance by a Physician and not obtained at a Student Health Center
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| Intercollegiate, Interscholastic, Intramural, or Club Sports | $5,000 Maximum per Injury or Illness Medical expenses only
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| All Other Eligible Medical Expenses | Usual, Reasonable and Customary charges
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| Dental Treatment Due to Accident | $250 Maximum per Tooth $500 Maximum per Certificate Period
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| Dental Treatment to Alleviate Pain | $100 Maximum per Certificate Period (not subject to Deductible or Coinsurance)
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| Emergency Medical Evacuation | $300,000 Participant Maximum Lifetime $50,000 Spouse Maximum Lifetime $50,000 Child Maximum Lifetime (not subject to Deductible or Coinsurance) | $250,000 Participant Maximum Lifetime $50,000 Spouse Maximum Lifetime $50,000 Child Maximum Lifetime (not subject to Deductible or Coinsurance) |
| Repatriation of Remains | $25,000 Maximum (not subject to Deductible or Coinsurance) | $15,000 Maximum (not subject to Deductible or Coinsurance)
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| Emergency Reunion | $2,500 Lifetime Maximum (not subject to Deductible or Coinsurance) | $1,000 Lifetime Maximum (subject to a maximum of 15 days, not subject to Deductible or Coinsurance) |
| Terrorism | $50,000 Maximum Lifetime Limit, Eligible Medical Expenses Only |
| Accidental Death & Dismemberment |
Principal Sum (Lifetime Maximum):
$25,000
Participant
$10,000
Spouse
$5,000
Child
Death – Principal Sum
Loss of 2 Limbs – Principal Sum
Loss of 1 Limb – One half Principal Sum Not subject to Deductible or Coinsurance | No Coverage |