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Drury University
2013 Benefit Guide
Group Number: LON12-120602-01LS
Effective Dates: 06/02/2013-05/31/2014
Your ID card contains important contact information and your individual certificate number, which you will need when you contact us. Finding a Provider:
U.S. PPO information for your plan can be found here: http://www.multiplan.com/search/search-2.cfm?originator=84453 Available by phone from our Assist Department 24/7
Inside the United States: 1-800-690-6295;
This Benefit Guide is a summary of
Outside the United States: 0-317-818-2808 (Collect)
emergency
information
and
Fax: 1-317-815-5984
instructions; it is not a substitute for
E-Mail: [email protected]
your review of the Certificate of
A complete list of international providers is also available at Wellabroad.com Insurance which has been provided.
For a full and detailed explanation
Wellabroad.com: Our real-time, information-rich Web site offers quick and easy
of
benefits,
provisions,
and
access to important and varied travel information free to our insureds. It contains exclusions from which claims are
travel advisories and warnings as well as country-specific background information processed
and
coverage
including entry requirements, languages, and airport locations. The site also provides determinations made, please refer
common travel resources such as international area codes, language tools and to
the
official
Certificate
of
currency and time zone converters. You will find a complete listing of international Insurance. If you do not have a copy
of the Certificate of Insurance,
MyPlan: This service area provides information about your eligibility, preferred
please immediately contact Seven
providers, and claims (including Explanation of Benefit forms). You may also contact us Corners for another copy.
through this area. Instructions for accessing MyPlan are provided on your ID card. Pre-Notification Guidelines: Your complete benefits often require that you give notice to Seven Corners either before or within 48
hours of receiving treatment. You must notify Seven Corners through our Assist department at the contact information shown above
by phone, fax, or e-mail.
1. You (or someone on your behalf) must notify Seven Corners 48 hours before a scheduled, non-emergency hospital
2. You (or someone on your behalf) must notify Seven Corners within 48 hours of an emergency hospital admission anywhere
3. You (or someone on your behalf) must notify Seven Corners 48 hours before incurring any expense in excess of US$1,000

Failure to pre-notify as stated will result in a reduction of benefits and/or an additional deductible.
Pre-notification does not guarantee payment of benefits.

Pre-Existing Condition means any condition for which medical advice or treatment was received or recommended within the six
months immediately preceding the effective date of coverage of the Insured person. This exclusion applies for 12 months after the
Insured person’s effective date of coverage. This exclusion does not apply to a pregnancy existing on the Insured person’s effective
date of coverage. This policy shall credit the time the Insured was previously covered under a previous health insurance plan or
policy or employer provided health benefit arrangement, if the previous coverage was continuous to a date not more than 63 days
prior to the effective date of the new coverage. Such credit shall apply to the extent that the previous coverage was substantially
similar to the new coverage. The creditable coverage outlined above means any prior health care coverage as defined in HIPAA
which includes group coverage; individual coverage; Medicare; Medicaid; military service related care; Indian health service or tribal
organization coverage; state health benefits risk pool; a public program offered under the Federal Employees Health Benefits
Program; a public health plan; Peace Corps Act health plan; state children’s health programs (S-CHIP); and foreign national health
plans.
This Benefit Guide is provided as a quick reference for emergency information and instructions. For a full and
detailed explanation of benefits, provisions, and exclusions from which claims are processed and coverage
determinations made, please refer to the official Certificate of Insurance available from Seven Corners.
Drury University
Eligibility: For all Applicants / Insured Persons: Any international student or scholar with a current non-immigrant visa who is
enrolled at Drury University is automatically enrolled in this insurance Plan at registration and the premium for coverage is added to
their tuition billing, unless proof of comparable coverage is furnished. Waivers may be granted to students who present acceptable
waiver forms and proof of comparable coverage. Persons with permanent residency status are not eligible to enroll in this plan.
Eligible Dependents, including spouse, and unmarried Dependent children under age 26 who have a similar visa and who accompany
the insured student while engaged in international educational activities are eligible to enroll in this insurance Plan on a voluntary
basis.
Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased. Home study, correspondence, Internet and television courses do not fulfill the Eligibility requirements that the student actively attend classes. Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the spouse and unmarried children under 26 years of age who are not self-supporting. Dependent Eligibility expires concurrently with that of the Insured student. Education or research activities shall mean the Insured: 1) is enrolled and participating in an educational, vocational, cultural exchange, or training programs; and 2) has a valid J-1, H-3, F, M, or Q Visa. It is the Insured Person’s responsibility to maintain all records regarding travel history, age and provide any documents to the Administrator, which would verify Eligibility Requirements. Exclusions:
The policy does not cover Loss nor provide benefits for:
1. Expenses for dental treatment, except for treatment resulting from Injury to natural teeth;
2. Services normally provided without charge by the Policyholder’s health service, infirmary, Hospital or employees;
3. Routine eye exams and contacts; replacing eyeglasses or prescription therefore; routine examinations and services related to
hearing examinations or hearing aids; or treatment for hearing defects not related to an Injury or Sickness; 4. Routine physical examinations; preventive care; elective surgery and elective treatment; services solely to improve appearance; for personal hygiene; [services specifically for dietary control;] custodial, sanitarial or rest care; or fertility testing; 5. Foot care including: flat foot conditions, care of corns, bunions (except capsular or bone surgery), calluses, weak feet, chronic 6. Cosmetic surgery. Cosmetic surgery does not include reconstructive surgery which results from trauma, infection or other diseases of the involved part; reconstructive surgery because of congenital disease or deformity of a dependent child. Cosmetic surgery due to congenital defects will be covered for newborn children; 7. Treatment or supplies for the newborn infant except that required for the treatment of a covered Accident or Sickness up to 48 8. Voluntary termination of pregnancy; 9. Skydiving; recreational parachuting; hang gliding; glider flying; parasailing; sail planing; bungee jumping; or flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; 10. Injury or Sickness resulting from any declared or undeclared war; 11. Injury due to participation in a riot; commission of or attempt to commit a felony; 12. Injury or Sickness while in the armed forces of any country. When an Insured enters such armed forces, We will refund the unearned pro rata premium to the Insured; 13. Injury or Sickness covered by any workers’ compensation or occupational disease law; 14. Injury or Sickness resulting from being under the influence of alcohol or drugs unless taken on a Physician’s advice; 15. Treatment provided in a governmental Hospital unless the Insured is legally obligated to pay such charges; 16. Injury sustained while (a) participating in any interscholastic, intercollegiate, club, or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c) while participating in any practice or conditioning program for such sport, contest or competition; unless the additional premium for Intercollegiate Sports Coverage 17. Pre-Existing Conditions; 18. Radiation Therapy; This Benefit Guide is provided as a quick reference for emergency information and instructions. For a full and
detailed explanation of benefits, provisions, and exclusions from which claims are processed and coverage
determinations made, please refer to the official Certificate of Insurance available from Seven Corners.
Drury University
19. Outpatient Physiotherapy; except for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2) within the 30 days immediately following the attending Physician’s release for 20. Prescription Drugs, services or supplies as follows: a) Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use; b) Immunization agents, biological sera, blood or blood products administered on an outpatient basis; c) Drugs labeled, “Caution - limited by federal law to investigational use” or experimental drugs, except as specifically provided in Benefits for Clinical Trial for Cancer Treatment; d) Products used for cosmetic purposes; e) Drugs used to treat or cure baldness; anabolic steroids used for body building; f) Anorectics - drugs used for the purpose of weight control; g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; h) Growth hormones; or i) Refills in excess of the number specified or dispensed after one (1) year of date of the prescription; 21. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversal of sterilization procedures; Schedule of Benefits
All Coverages and Plan Costs listed in this Evidence of Benefits are in U.S. Dollar amounts. Maximum Benefit per
Period of Coverage
Deductible
$100 per occurrence. The deductible for students will be waived when treatment is rendered at the Student Health Center, referral was provided by the Student Health Center, treatment is provided more than 50 miles from campus, or when Student Health Center is closed. Coinsurance In Network
After the deductible, the policy pays 100% of eligible expenses to the policy maximum. Coinsurance Out of
After the deductible, the policy pays 80% eligible expenses to the policy maximum. Network
Hospital Room and Board
When Your Injury or Sickness requires Hospital confinement, We will pay the Hospital room and board Expense up to the semi-private rate. Benefit also applies to Intensive Care Unit. Subject to deductible and coinsurance. Hospital Miscellaneous
We will pay the Expenses incurred by You during a Hospital confinement or as an outpatient for day surgery for services provided by a Hospital, ambulatory surgical center or ambulatory medical center. We will pay for anesthesia, operating room, laboratory tests, x-rays, oxygen, drugs, medicines, dressings, and other necessary non-room and board Expenses. Subject to deductible and coinsurance. Surgical Expense
When Your Injury or Sickness requires surgery, We will pay the Expense based on the MDR (Medical Data Research) survey of surgical fees valued at the 90th percentile. Only one surgical procedure will be covered when multiple procedures are performed unless Medically necessary. Subject to deductible and coinsurance. Anesthetist
If the surgery requires the services of an anesthetist who is not employed or retained by the Hospital in which the surgery is performed, We will pay the Expense. Subject to deductible and coinsurance. In-Hospital Physician Fee
If, while confined to a Hospital, Your Injury or Sickness requires the services of a Physician, We will pay the Expense for such services. Subject to deductible and coinsurance. Outpatient Physician
When Your Injury or Sickness requires the services of a Physician, while not confined to a Hospital, We will pay the Expense. Subject to deductible and coinsurance. Physical Therapy Expense When Your Injury or Sickness requires Physical Therapy, including, but not limited to diagnosis, evaluation,
diagnostic, x-ray/lab, and therapeutic modalities, We will pay the expense up to 5 visits. Subject to deductible and coinsurance. Consultant or Specialist
When Your Injury or Sickness requires the services of a consultant or specialist, as requested by the attending Physician, We will pay the Expense. Subject to deductible and coinsurance. Licensed Nurse Expense
If, while confined in a Hospital, Your Injury or Sickness requires the services of an R.N. or licensed practical nurse, We will pay the Expense. Subject to deductible and coinsurance. Ambulance Expense
When Your Injury or Sickness requires the use of an ambulance or air ambulance, We will pay the Expense. Subject to deductible and coinsurance. This Benefit Guide is provided as a quick reference for emergency information and instructions. For a full and
detailed explanation of benefits, provisions, and exclusions from which claims are processed and coverage
determinations made, please refer to the official Certificate of Insurance available from Seven Corners.
Drury University
Schedule of Benefits (continued)

Diagnostic X-ray &
When Your Injury or Sickness requires diagnostic x-ray, including ultrasound, MRI, and CAT Scan, or laboratory Laboratory Expense
services, under the Physicians direction, We will pay the Expense. Subject to deductible and coinsurance. Hospital Outpatient
When Your Injury or Sickness requires the use of outpatient facilities of an emergency room, under the Physician’s direction, We will pay the Expense. Subject to deductible and coinsurance. Prescribed Medicines
When Your Injury or Sickness requires prescribed medicines, including contraceptives, We will pay the Expense. Subject to deductible and coinsurance of 80% to $2,500 per Injury or Sickness Preadmission Testing
When Your Injury or Sickness requires Preadmission Testing, We will pay the Expense. Subject to deductible and coinsurance. Emergency Medical
When Your Injury or Sickness requires Emergency Medical care, We will pay the Expense. Subject to deductible and coinsurance. 2nd Surgical Opinion
When Your Injury or Sickness requires a 2nd Surgical Opinion, We will pay the Expense. Subject to deductible and coinsurance. Durable Medical
When your Injury or Sickness requires the use of durable medical equipment or supplies, We will pay for the rental charge or the purchase of new equipment, whichever is less. Subject to deductible and coinsurance. STD Testing
When Your Sickness requires STD testing, We will pay the expense. Subject to deductible and coinsurance. Outpatient Mental Illness
We will pay the Expense for recognized mental illness while not Hospital confined, including treatment through partial or full-day program services, for mental health services for a recognized mental illness rendered by a licensed professional to the same extent as any other Sickness. Please refer to the certificate for a full and detailed explanation of benefit. Subject to deductible and coinsurance. Outpatient Chemical
When You require treatment for chemical dependency, We will pay the Expense for the following: outpatient Dependency Expense
treatment through a nonresidential treatment program, or through partial or full-day program services, of not less than 26 days per benefit period. The coverages set forth above shall be subject to a separate lifetime frequency cap of not less than ten episodes of treatment. Please refer to the certificate for a full and detailed explanation of benefit. Subject to deductible and coinsurance. Inpatient Chemical
When You require inpatient treatment for chemical dependency, We will pay the Expense for the following: Dependency Expense
1)a residential program of not less than 21 days per benefit period 2) medical or social setting detoxification of not less than six days per benefit period. The coverages set forth above shall be subject to a separate lifetime frequency cap of not less than ten episodes of treatment. Please refer to the certificate for a full and detailed explanation of benefit. Subject to deductible and coinsurance. Claims Submission
Documents required for submitting a claim include the following:
1. Completed Proof of Loss (Claim form) - can be found at: http://www2.sevencorners.com/downloads/Lloyds_Student_Group.pdf 2. Detailed bills for services received. 3. Receipts for payments made. 4. Any other supporting medical documentation pertinent to the claim. Claims documents may be submitted via postal mail, fax, or email: Seven Corners, Inc. Attn. Claims 303 Congressional Blvd. Carmel, IN 46032 UNITED STATES Fax: (+01) 317-575-2256 Email: [email protected] Claims which do not require additional medical documentation are processed within 30-45 days of receipt. Member reimbursement may be issued via bank check or wire transfer, depending on the member’s preference. It is important to answer all questions on the claim form with as much detail as possible. Currency conversions for claims are paid based on the exchange rate for the U.S. dollar on your date of service.
This Benefit Guide is provided as a quick reference for emergency information and instructions. For a full and
detailed explanation of benefits, provisions, and exclusions from which claims are processed and coverage
determinations made, please refer to the official Certificate of Insurance available from Seven Corners.

Source: http://www.eglobalhealth.com/files/Drury_University_Benefit_Guide_2013-14.pdf