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Table of Contents Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Effective And Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 UnitedHealthcare Network Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Benefits for Accidental Ingestion of a Controlled Drug . . . . . . . . . . . . . . . . . . . . . . . . . .7 Benefits for Hypodermic Needles or Syringes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Benefits for Reconstructive Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Benefits for Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Benefits for Mammography and Comprehensive Ultrasound Screening . . . . . . . .9 Benefits for Ostomy Appliances and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Benefits for Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Benefits for Treatment of Tumors and Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Benefits for Prostate Cancer Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Benefits for Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Benefits for Cancer Clinical Trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Benefits for Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Benefits for Amino Acid Modified Preparations and Low Protein Modified Food Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Benefits for Lyme Disease Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Benefits for Isolation Care and Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Benefits for Diabetic Outpatient Self-Management Training . . . . . . . . . . . . . . . . . . .12 Benefits for Inpatient Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Treatment of Craniofacial Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Mental or Nervous Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Benefits for Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Benefits for Infertility Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Benefits for Epidermolysis Bullosa Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Exclusions And Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 General Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . .17 Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back Cover
THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDE COMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR LIMITED BENEFITS POLICY AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS PLAN IS NOT DESIGNED TO COVER THE COSTS OF SERIOUS OR CHRONIC ILLNESS. IT CONTAINS SPECIFIC DOLLAR LIMITS THAT WILL BE PAID FOR MEDICAL SERVICES WHICH MAY NOT BE EXCEEDED. IF THE COST OF SERVICES EXCEEDS THOSE LIMITS, THE INSURED AND NOT THE COMPANY IS RESPONSIBLE FOR PAYMENT OF THE EXCESS AMOUNTS. THE SPECIFIC DOLLAR LIMITS ARE SPECIFIED IN THE SCHEDULE OF BENEFITS. Privacy Policy We know that your privacy is important to you and we strive to protect the confidentiality of your nonpublic personal information. We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted or required by law. We believe we maintain appropriate physical, electronic and procedural safeguards to ensure the security of your nonpublic personal information. You may obtain a copy of our privacy practices by calling us toll-free at 800-767-0700 or by visiting us at www.uhcsr.com. Eligibility All Domestic students registered for credit courses are eligible to enroll in this insurance Plan. All International students registered for credit courses are automatically enrolled in this insurance Plan at registration, unless proof of comparable coverage is furnished. Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased. The Company maintains its right to investigate student status and attendance records to verify that the policy Eligibility requirements have been met. If the Company discovers the Eligibility requirements have not been met, its only obligation is to refund premium. Alternative Coverage - If you do not meet the Eligibility requirements of the Plan, please call 1-800-406-2338 for more information on alternative coverage. This information can also be accessed at http://www.goldenrulehealth.com/studentresources. Effective And Termination Dates The Master Policy on file at the school becomes effective at 12:01 a.m., August 15, 2012. Coverage becomes effective on the first day of the period for which premium is paid or the date the enrollment form and full premium are received by the Company (or its authorized representative), whichever is later. The Master Policy terminates at 11:59 p.m., June 15 2013. Coverage terminates on that date or at the end of the period through which premium is paid, whichever is earlier. Refunds of premiums are allowed only upon entry into the armed forces. The Policy is a Non-Renewable One Year Term Policy. 1
Page 1 and 2: Suffield Academy Registration Packe
Page 3 and 4: suffield academy Suffield, Connecti
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Page 19: 2012-2013 STUDENT INJURY AND SICKNE
Page 23 and 24: Schedule of Medical Expense Benefit
Page 25 and 26: OTHER Ambulance Services, when medi
Page 27 and 28: 4. Drugs available over-the-counter
Page 29 and 30: Home health care shall consist of,
Page 31 and 32: Benefits for Postpartum Care If an
Page 33 and 34: Benefits for Pain Management Benefi
Page 35 and 36: 13. Immunizations, except as specif
Page 37 and 38: Scholastic Emergency Services: Glob
Page 43 and 44: Since 1921 Since 1921 6078 • (860
Page 45 and 46: 06078 • (860) 668-7315 • Fax (8
Page 47 and 48: Dear Sufüeld Academy Parents and S
Page 49: [ [ suffield academy [ Suffield, Co

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