Student Insurance Information

For all questions please call (219) 464-5400

Valparaiso University is interested in promoting good health practices as well as preventing sickness and accidents among students. The University does not assume financial responsibility for a student in case of illness or accident. The University maintains the Student Health Center for the treatment of minor illnesses and minor accidents. The services of the physician and nurses and some minor laboratory tests are provided to students at no charge. Illnesses or accidents which require more extensive treatment or services are referred to the local hospital or to physicians in the community. Students or their parents are responsible for the costs of such treatment if it is not covered by the Plan.

The Plan consists of 2 separate policies. The policy represented by Plan A is accident-only and the policy represented by Plan B is fixed indemnity sickness-only.

The plans are provided for all full-time students (undergraduate, graduate, and law) who pay the full general fee to the University. The cost is covered by the general fees which a student pays at the beginning of each semester. Benefits are provided up to specified limits as described in this pamphlet. The coverage is not designed to provide benefits for all medical costs.

The student or parents will be responsible for costs over and above policy benefits.

Only the Plan B–fixed indemnity-sickness only plan is available for dependents of insured students of Valparaiso University for the same period of coverage as the student. A student wanting to insure his/her dependents must complete the dependent enrollment form and return to the Student Affairs Office no later than September 27, 2013. New students enrolling into the spring semester may also enroll their dependents. The deadline to enroll dependents is February 7, 2014.

ELIGIBILITY

All full-time graduate students who are enrolled for 9 credit hours or more and pay the full general fee and full-time undergraduate and full-time law students who are enrolled for 12 credit hours or more and pay the full general fee will be covered under Plan A and Plan B. New students beginning full-time enrollment at the University during summer must carry at least six (6) credit hours per summer term and pay the full general fee to be eligible for coverage under Plan A and Plan B.

GENERAL INFORMATION

The policy is underwritten by National Guardian Life Insurance Company and is serviced by Wells Fargo Insurance Services USA, Inc., P.O. Box 276, Columbus, Ohio 43216-0276. All claims will be paid by Special Risk Claims, Commercial Travelers Mutual Insurance Company, 70 Genesee Street, Utica, NY 13502. For injuries incurred in the practice or participation in intercollegiate athletics, benefits under Plan A will be coordinated with the college-sponsored athletic coverage.

WHEN COVERAGE BEGINS AND ENDS

1. Coverage becomes effective on August 11, 2013.

Coverage continues during the period for which the premium has been paid. The Master Policy expires at 12:01 a.m. on August 11, 2014.

2. Coverage is automatically canceled when a student terminates his/her association as a full-time student with Valparaiso University.

3. Protection is in effect during all interim vacation periods.

PLAN A—ACCIDENT-ONLY BENEFITS

Participation Basis:

Mandatory: Domestic Full-time Undergraduate, Graduate and Law Students

Benefit Period: 52 weeks

Coverage Period: 8/11/13 thru 8/10/14

Provided under Policy No. 2013M3B32

MAXIMUM MEDICAL BENEFIT

Coverage A—Athletic Activities: $5,000

Coverage B—Non-Athletic Activities: $500

If the insured person incurs eligible expense as the result of a covered injury, the company will pay the charges incurred for such expense within the benefit period, beginning on the date of the accident. Payment will be made for eligible expenses in excess of the applicable deductible amount, not to exceed the maximum medical benefit. The first such expense must be incurred within 60 days after the date of accident.

Coverage A—Athletic Activities: While participating during the official season of a sport as a member of an interscholastic, intercollegiate, intramural or club athletic team of the policyholder. Participation must be: in a regularly scheduled and approved practice session or game of the policyholder named in the policy schedule; and under the supervision of proper adult authority of the policyholder; or traveling directly to or from the above with other members of the team under the supervision of the proper adult authority of the policyholder; or

Coverage B—Non-Athletic Activities: Within a school building or on the school grounds during regular school hours on a regular school day; away from school premises while participating in an activity solely sponsored and supervised by the school authorities, during the regular school term; or away from school premises while coverage is in force.

PLAN A—EXCLUSIONS AND LIMITATIONS

The policy does not cover any loss contributed to or resulting from:

1. Sickness or disease in any form (except pyogenic infections due to an accidental cut or wound).

2. The use of drugs or narcotics; unless administered on the advice of a physician.

3. War or any act of war, whether or not declared

4. Participation in any riot or civil commotion.

5. Air travel; or the use of any device or equipment for aerial navigation; except as a fare-paying passenger on a regularly scheduled commercial airline; or as a passenger on a flight chartered by the school.

6. Suicide, attempted suicide, or intentionally self-inflicted injury.

7. Hernia, in any form.

8. Fighting or brawling, except in self-defense.

9. Use of electric, bio-mechanical devices.

10. Expenses incurred for the use of orthotics unless solely to promote healing.

11. Off season physical conditioning for interscholastic, intercollegiate, intramural, or club sports; unless noted on the policy schedule.

The policy does not cover treatment administered by any person or facility employed or retained by the policyholder; or by any member of the insured's family or household. This includes a team physician, team trainer or nurse.

PLAN A—NON-DUPLICATION OF INSURANCE PROVISION

The policy does not cover treatment or service for which benefits are payable or service is available under any other valid and collectible insurance. This includes Worker's Compensation and automobile no-fault insurance. Benefits under the Policy are limited to expenses that are in excess of benefits payable under other valid and collectible insurance.

PLAN B—SICKNESS-ONLY

FIXED INDEMNITY BENEFITS

Participation Basis–Domestic Full-time

Undergraduate, Graduate and Law Students–Mandatory

Dependents of Eligible Students–Voluntary

Benefit Period: Policy Term

Coverage Period: 8/11/13 thru 8/10/14

Provided under Policy No. 2013M3B33

SCHEDULE OF BENEFITS

The following provisions describe the benefits we will pay for covered services. We will pay benefits for a covered service only once, even if the service could be included under more than one benefit description.

Hospital Confinement Daily Income Benefit

Non-critical care unit daily benefit. . . . . . . . . . . . . . $100

Maximum benefit for non-critical care unit per coverage period . . . . . . . . . . . . . . . . . . . 10 Days

Critical care unit daily benefit . . . . . . . . . . . . . . . . . $100

Maximum benefit for critical care unit per coverage period . . . . . . . . . . . . . . . . . . . . 5 Days

Recurrent period. . . . . . . . . . . . . . . . . . . . . . . . 90 Days

Hospital Discharge Benefit

Hospital discharge amount per day of inpatient confinement. . . . . . . . . . . . . . . . . . . . . . . . . . . $100

Maximum benefit per coverage period . . . . . . . . . . . $100

Maximum number of hospital discharges per coverage period . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Surgery Benefit

For surgery performed as an inpatient . . . . . . . . . . . $300

For surgery performed as an outpatient . . . . . . . . . . $300

Administration of Anesthesia Benefit

Per administration amount 10% of the corresponding surgery benefit

For surgery performed as an inpatient . . . . . . . . . . . . $30

For surgery performed as an outpatient . . . . . . . . . . . $30

Doctors' Visits Benefit

Consultation per visit amount (1 visit per coverage period). . . . . . . . . . . . . . . . . . . . . . . . $100

Private-duty Nursing Care and Home Health Care Benefit

Per session/visit amount . . . . . . . . . . . . . . . . . . . . . $50

Maximum benefit per coverage period . . . 2 sessions/visits

Ambulance Transportation Benefit

Per trip amount (1 trip per coverage period) . . . . . . . $75

Emergency Room Visits Benefit

Per visit amount for the treatment of a sickness

(1 visit per coverage period) . . . . . . . . . . . . . . . $200

Diagnostic Laboratory Tests Benefit

Per visit amount (2 visits per coverage period) . . . . . . $50

Diagnostic Radiology Tests Benefit

All other radiology tests per visit amount

(2 visits per coverage period) . . . . . . . . . . . . . . $100

PLAN B—EXCLUSIONS

No benefits will be paid for loss caused by or resulting from:

a) intentionally self-inflicted injuries, suicide or any attempt thereat while sane or insane;

b) declared or undeclared war or any act thereof;

c) the covered person's commission of a felony;

d) the covered person's participation in, practice for, or orthopedic equipment and appliances used for intercollegiate sports; semi-professional sports; or professional sports, (except as specified in the coverage descriptions);

e) work-related injury or sickness.

In addition to the above exclusions, no benefits will be paid for:

a) eye examinations for glasses; any kind of eye glasses, or prescriptions for any eyeglasses except as required as a result of a covered injury;

b) normal health checkups;

c) hearing examinations or hearing aids except as required as a result of a covered injury;

d) dental care or treatment other than covered services rendered in connection with the care of sound, natural teeth and gums required on account of injury to the covered person resulting from an accident that happens while covered under the policy, and rendered within 12 months of the accident;

e) care or treatment of allergies, including allergy testing;

f) diagnosis and care or treatment of acne;

g) care or treatment rendered in connection with cosmetic surgery, except covered services rendered in connection with cosmetic surgery the covered person needs for breast reconstruction following a mastectomy or as a result of an accident that happens while covered under the policy. Cosmetic surgery for an accidental injury must be performed within 90 days of the accident causing the injury and while such person's coverage is in force;

h) care or treatment rendered in connection with surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices other than as specifically provided above;

i) services provided by a member of the covered person's immediate family;

j) services provided by the policyholder’s infirmary or its employees, or doctors who work for the policyholder or any Student Health Center. PLAN B—EXTENSION OF BENEFITS

If coverage under the policy ends while the covered person is totally disabled due to injury or sickness, we will pay benefits for covered services occurring after the date coverage under the policy ends as long as they meet the following requirements: a) the covered service must be rendered due to the same injury or sickness causing the covered person to be totally disabled on the date coverage ends; and b) the covered service must occur within 90 days after the date the covered person's coverage under the policy ends; and c) coverage must not have ended as a result of the covered person's or, in the case of a dependent child, the child's parent’s voluntary termination of the coverage. This extension of benefits terminates at the end of the 90- day period specified above.

As used in this section, totally disabled means: a) with respect to a covered person who would otherwise be employed, the complete inability to perform all of the substantial and material duties of such person's occupation; and b) with respect to a covered person who is not otherwise gainfully employed, confinement as an inpatient in a hospital.