Student Health AdvantageSM Platinum
All amounts shown are in U.S. dollars.
All amounts shown are in U.S. dollars.
| Summary of Benefits | |
| Maximum Limit |
Student- $1,000,000 Dependent- $100,000 |
| Maximum Limit per Illness or Injury |
Student- $500,000 Dependent- $100,000 |
| Deductible |
For treatment received outside of the U.S.: $25 per illness or injury For treatment received within the U.S.: PPO provider: $25 per illness or injury; Non-PPO provider: $50 per illness or injury; Student health center: $5 copay per visit |
| Coinsurance |
Outside of the U.S.: Company pays 100% In PPO Network or Student Health Center within the U.S.: Company pays 100% Out of PPO Network if within the U.S.: Company pays 80% of eligible expenses up to $5,000; then 100% thereafter |
| Eligible Medical Expenses | After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally |
| COVID-19/SARS-CoV-2 Coverage | COVID-19/SARS-CoV-2 shall be considered by the Company the same as any other Illness or Injury, subject to all other Terms and conditions of this insurance |
| Teladoc Consultation (Groups only) | Company pays 100% within the U.S.; mental and nervous disorders not covered |
| Hospital Room and Board | Average semi-private room rate, including nursing service |
| Maternity and Newborn Care | $5,000 maximum limit. Benefit includes newborn routine care during the first 31 days of life. After deductible is met, company pays 60% of eligible expenses out-of-network (U.S.), 80% in-network (U.S.) and 100% internationally |
| Hospital Emergency Room Injury | Company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally. Not subject to emergency room deductible |
| Hospital Emergency Room Illness | After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally. Subject to a $250 deductible for each visit that doesn’t result in a direct hospital admission |
| Intensive Care | After deductible is met, company pays 80% of expenses out-of-network (U.S) or 100% in-network (U.S.) and internationally |
| Mental or Nervous / Substance Abuse |
Outpatient- $50 per day; $500 maximum limit; Inpatient: After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally up to $10,000 maximum limit; Student Health Center Treatment: $0 |
| Prescription Drugs and Medication | After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally; $250,000 period of coverage limit for insured student and $100,000 period of coverage limit for dependents. Retail pharmacy prescription drugs and medication are paid at 50% outof- network and international with a 90 day dispensing maximum. |
| Physical Therapy (Medical order or treatment plan required) | After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally; limit one visit per day |
| Emergency Local Ambulance | $750 per illness resulting in an inpatient hospitalization or injury |
| Dental | Non-emergency treatment at a dental provider due to an accident - $500 period of coverage limit per injury; Unexpected pain to sound, natural teeth - $350 period of coverage limit |
| Interfacility Ambulance Transfer (For services rendered in the U.S.) | Company pays 100%. Transfer must be a result of an inpatient hospital admission |
| Emergency Medical Evacuation | $500,000 maximum limit |
| Emergency Reunion | $50,000 maximum limit |
| Return of Mortal Remains | $50,000 maximum limit |
| Political Evacuation and Repatriation | $10,000 maximum limit |
| Intercollegiate/Interscholastic/ Intramural or Club Sports | $5,000 period of coverage limit per illness or injury |
| Incidental Trip Coverage | Up to a cumulative 14 days (available for non-U.S. residents only) |
| Pre-existing Conditions | Charges excluded until after six months of continuous coverage |
| Terrorism | $50,000 maximum limit |
| Accidental Death & Dismemberment | Student: $25,000 principal sum; spouse: $10,000 principal sum; dependent child: $5,000 principal sum; accidental dismemberment percentage of principal sum |
| Personal Liability (Secondary to any other insurance) | $10,000 combined maximum limit Injury to third person: subject to a $100 per injury deductible Damage to third person's property: subject to a $100 per damage deductible |
* 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.