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Student Health AdvantageSM Platinum
Student Health AdvantageSM Platinum

All amounts shown are in U.S. dollars.
Coverage Limit / Maximum Amount for Eligible Medical Expenses
Benefits In-Network Out-of-Network International
Maximum Limit Student: $1,000,000 Dependent: $100,000 Student: $1,000,000 Dependent: $100,000 Student: $1,000,000 Dependent: $100,000
Per Illness or Injury limit Student: $500,000 Dependent: $100,000 Student: $500,000 Dependent: $100,000 Student: $500,000 Dependent: $100,000
Deductible Options
  • Per Illness or Injury
 $100 $150 $25
Coinsurance for Eligible Medical Expenses
Benefits In-Network Out-of-Network International
Coinsurance
  • In addition to Deductible
 Plan pays 90%
Insured pays 10%		 Plan pays 80%
Insured pays 20%		 Plan pays 100%
Insured pays 0%
Out of Pocket Maximum $1,000 Up to the Maximum Limit $0
Precertification
Benefits In-Network Out-of-Network International
Interfacility Ambulance Transfer, Emergency Medical Evacuation No coverage if Pre-certification requirements are not met No coverage if Pre-certification requirements are not met No coverage if Pre-certification requirements are not met
Maternity 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met
All other Treatments & supplies 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met
Pre-existing Conditions
Benefits In-Network Out-of-Network International
Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded until the Insured Person has maintained 6 months of continuous coverage under this insurance.
Student Health Center
Benefits In-Network Out-of-Network International
Copayment per visit
  • Not subject to the per Illness or Injury Deductible
$5 $5 $5
Coinsurance Plan pays 100%
Insured pays 0%		 Plan pays 100%
Insured pays 0%		 Plan pays 100%
Insured pays 0%
Inpatient/Outpatient Benefits
Benefits In-Network Out-of-Network International
Eligible Medical Expenses 90% 80% 100%
Physician Visits/Services
  • Maximum Visits per day: 1
  • Surgery is not subject to the Maximum visit limit
 90% 80% 100%
Hospital Emergency Room
  • Injury: Not subject to Emergency Room Deductible
  • Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission.
90% 80% 100%
Teledoc Consultation (Groups only)
  • Not subject to Deductible and Coinsurance
  • Mental or Nervous Disorders are not covered
  • Coverage for a Teladoc Consultation is not a determination that any specific condition discussed, raised or identified during such consultation is covered under this insurance. The Company reserves the right to decline future claims relating to or arising from any condition discussed, raised or identified during a Teladoc Consultation where the Illness or Injury is directly or indirectly related to any Pre-existing Condition or is otherwise excluded under this Certificate of Insurance
Hospitalization / Room & Board
  • Average semi-private room rate
  • Includes nursing, miscellaneous and Ancillary Services
90% 80% 100%
Intensive Care 90% 80% 100%
Outpatient Surgical / Hospital Facility 90% 80% 100%
Laboratory 90% 80% 100%
Radiology / X-ray 90% 80% 100%
Chemotherapy / Radiation Therapy 90% 80% 100%
Pre-admission Testing 90% 80% 100%
Surgery 90% 80% 100%
Reconstructive Surgery
  • Surgery is incidental to and follows Surgery that was covered under the plan
 90% 80% 100%
Assistant Surgeon
  • 20% of the primary surgeon’s eligible fee
 90% 80% 100%
Anesthesia 90% 80% 100%
Maternity and Newborn Care
  • ƒ Maximum Limit: $5,000
  • ƒ Pre-natal care, delivery of a Newborn, and post-natal care of an Insured Person, including complications
  • Newborn routine care during the first 31 days of life
 80% 60% 100%
Durable Medical Equipment 90% 80% 100%
Chiropractic Care
  • Medical order or Treatment plan required
 90% 80% 100%
Physical Therapy
  • Maximum Visits per day: 1
  • Medical order or Treatment plan required
90% 80% 100%
Extended Care Facility
  • Upon direct transfer from an acute care Hospital
 90% 80% 100%
Home Nursing Care
  • Provided by a Home Health Care Agency
  • Upon direct transfer from an acute care Hospital
90% 80% 100%
Prescription Drugs and Medication - The following Prescription Drugs and Medication Period of Coverage limit accumulates toward the Maximum Limit
Benefits In-Network Out-of-Network International
Period of Coverage limit
  • Subject to the Coinsurance amounts listed below
  • Primary Insured Person: $250,000 per person
  • Spouse and Child: Up to the Maximum Limit ($100,000)
  • Primary Insured Person: $250,000 per person
  • Spouse and Child: Up to the Maximum Limit ($100,000)
  • Primary Insured Person: $250,000 per person
  • Spouse and Child: Up to the Maximum Limit ($100,000)
Inpatient and Outpatient Surgery Prescription Drugs and Medication 90% 80% 100%
Emergency Room and Outpatient Office Visits
Prescription Drugs and Medication		 90% 80% 100%
Retail Pharmacy Prescripton Drugs and Medication
  • Dispensing maximum for Retail Pharmacy: 90 days per prescription
 N/A 50% 50%
Mental or Nervous / Substance Abuse
Benefits In-Network Out-of-Network International
Inpatient Mental or Nervous / Substance Abuse
  • Maximum Limit: $10,000
  • Not covered if incurred at the Student Health Center
90% 80% 100%
Outpatient Mental or Nervous / Substance Abuse
  • Maximum Limit per day: $50
  • Maximum Limit: $500
  • Not covered if incurred at the Student Health Center
90% 80% 100%
Emergency Services
Benefits In-Network Out-of-Network International
Emergency Local Ambulance
  • Period of Coverage Limit per Injury $750
  • Period of Coverage Limit per Illness $750 (resulting in an Inpatient Hospitalization)
100% 100% 100%
Emergency Medical Evacuation
  • Maximum Limit: $500,000
  • Must be approved in advance and coordinated by the Company
100% 100% 100%
Emergency Reunion
  • Maximum Limit: $50,000
  • Maximum Days: 15
  • Meal Maximum per day: $25
  • Reasonable and necessary travel costs and accommodations
  • Must be approved in advance by the Company
100% 100% 100%
Interfacility Ambulance Transfer
  • Up to the per Injury or Illness limit
  • Services rendered in the United States
  • Transfer must be a result of an Inpatient Hospital admission
100% 100% N/A
Political Evacuation and Repatriation
  • Maximum Limit: $10,000
  • Must be approved in advance by the Company
100% 100% 100%
Repatriation for Medical Treatment
  • Maximum Benefit: $100,000
  • Approved in advance and coordinated by the Company
  • Refer to the REPATRIATION FOR MEDICAL TREATMENT provision for further details
100% 100% 100%
Return of Mortal Remains
  • Maximum Limit: $50,000
  • Local Burial / Cremation at place of death
  • Maximum Limit: $5,000
  • Return of Insured Person’s Mortal Remains to Country of Residence
  • Must be approved in advance by the Company
100% 100% 100%
Other Services
Benefits In-Network Out-of-Network International
Terrorism
  • ƒ Not subject to Deductible and Coinsurance
  • Maximum Limit: $50,000
 100% 100% 100%
Dental Treatment
  • Period of Coverage Limit: $350
  • (Treatment due to Unexpected pain to sound, natural teeth)
  • Period of Coverage Limit per Injury: $500
(Non-emergency Treatment at a Dental Provider due to an Accident) 		N/A 90% 100%
Traumatic Dental Injury
  • Treatment at a Hospital Facility due to an Accident
  • Additional Treatment for the same Injury rendered by a Dental Provider will be paid at 100%
90% 80% 100%
Intercollegiate, Interscholastic, Intramural, or Club Sports
  • Period of Coverage Limit per illness or injury: $5,000
90% 80% 100%
Accidental Death & Dismemberment
  • Not subject to Deductible and Coinsurance
  • Death must occur within 90 days of the Accident
Accidental Death: 100% of Principal Sum
Student: $25,000
Spouse: $10,000
Child: $5,000
Accidental Dismemberment:
Loss Percent of Principal Sum
Sight of 1 eye 50%
1 hand or 1 foot 50%
1 hand and loss of sight of 1 eye 100%
1 foot and loss of sight of 1 eye 100%
1 hand and 1 foot 100%
Both hands or both feet 100%
Sight of both eyes 100%
Incidental Trip
  • Maximum days: 14
  • Country of Residence is outside the United States
  • Refer to the INCIDENTAL TRIP provision for further details
90% 80% 100%
Personal Liability
  • Secondary to any other insurance
  • No coverage for Injury to a related Third Party or damage to related Third Person’s property
  • Refer to the PERSONAL LIABILITY provision for further details and requirements
Combined Maximum Limit: $10,000

Injury to Third Person:
Per Injury Deductible: $100

Damage to Third Person’s property: Per damage Deductible: $100 		Combined Maximum Limit: $10,000

Injury to Third Person:
Per Injury Deductible: $100

Damage to Third Person’s property: Per damage Deductible: $100 		Combined Maximum Limit: $10,000

Injury to Third Person:
Per Injury Deductible: $100

Damage to Third Person’s property: Per damage Deductible: $100

* This Web page contains only a consolidated and summary description of all current benefits, conditions, limitations and exclusions. A certificate containing the complete Certificate Wording with all terms, conditions and exclusions will be included in the fulfillment kit. IMG reserves the right to issue the most current Certificate Wording for this insurance plan in the event this Web page, application, and/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request.

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