john@bfsnow.com
www.balancedfinancialsolutions.com
Student Health AdvantageSM Platinum
Student Health AdvantageSM Platinum

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
Hospital Room and Board Average semi-private room rate, including nursing service
Intensive Care After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally
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
Emergency Room Injury After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally
Emergency Room Illness resulting in Hospitalization After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally
Emergency Room Illness without Inpatient Admission After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally; Subject to additional $250 deductible
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 Inpatient: After deductible is met, company pays 80% of expenses out-of- network (U.S.) or 100% in-network (U.S.) and internationally
Outpatient: 50% of actual charges
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
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
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
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
AD&D 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.