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Domestic Accident Only Plan 2013-2014

VENDOR: AIG INSURANCE COMPANY

Insurance cards will be available online from the AIG website after September 11, 2013.

POLICY LIMITS – When a covered injury requires treatment by a physician, this policy will provide benefits for 52 weeks from the date of the injury for the limits of the policy. The policy will allow benefits for expenses not covered by other valid and collectible coverage.

 

SCHEDULE OF ACCIDENTAL ONLY BENEFITS

Maximum Benefit: $15,000;

Eligibility

Domestic Students meeting the specified hours, all UL Lafayette Year-Round Visiting Groups: Boarding Programs and Day Camps

Type of coverage

Excess to any other valid / collectible health insurance coverage.

Benefit Period

For 52 weeks from the date of the Injury for the limits of the policy

Deductible

$0

POLICY FEATURES

ACCIDENT ONLY

Inpatient Hospital Services

Hospital Room and Board Expense

100% U & C

Semi-Private Room Rate

Intensive Care Room and Board

100% U & C

Hospital Miscellaneous Expense

100% U & C

Outpatient Hospital Services

Emergency Room: When Hospital Confinement is not required, including all services billed by the facility

100 % U & C

Ambulatory Medical Centers and Outpatient Operating Room

100 % U & C

Physician Services

Surgery, including pre- and post-operative care:

When a covered injury requires 2 or more covered surgical procedures which are performed through the same approach and at the same time or immediate succession, the Company will pay full value for the most expensive procedure and 50% of the value for the 2nd procedure performed and 25% of the value for any additional procedures performed.

100 % U & C

Anesthesia (including administration)

100 % U & C

Assistant Surgeon when medically necessary

100 % U & C

Physician’s visits other than for Physiotherapy or similar treatment when no surgery benefit is paid, beginning on the first day treatment is rendered

100 % U & C

Consultant and second opinions when required by attending Physician for confirming or determining a diagnosis, but not for treatment

100 % U & C

X-RAY, MRI and Laboratory Services

Diagnostic X-rays

100 % U & C

Laboratory Services

100 % U & C

MRI / Cat Scan

100 % U & C

Additional Services

Physiotherapy

100 % U & C

Ambulance Services

100 % U & C

Durable Medical Equipment

100 % U & C

Drugs and medications, when prescribed by a Physician

100 % U & C

Eye Glasses, Contact Lenses and Hearing Aids: Replacement of broken glasses and / or frames, contact lenses and hearing aids resulting from a covered injury

100 % U & C

Dental Services

Treatment, repair or replacement of each injured natural tooth: This will include Expenses Incurred for initial braces when required for treatment of a Covered Injury, examination, diagnosis, X-Rays, restorative treatment, endodontics and oral surgery, and treatment for gingivitis resulting from trauma.

100 % U & C

Part B: Accidental death and dismemberment. To provide for accidental death or accidental dismemberment for loss occurring within one hundred (100) days from the date of the accident, according to the following schedule

Accidental Death $2,500

Entire sight of both eyes $2,500

Both hands or feet $2,500

One hand or one foot or one eye $1,500

Thumb and index finger on either hand $750