CIEE Insurance Coverage Overview

This section includes some of the definitions applicable to the plan and are defined below.

Accident: A sudden, unintentional, and unexpected occurrence caused by external, visible means and resulting in physical Injury to the Insured Person.

Agreement to Provide Insurance: The Agreement to Provide Insurance entered into by the Company and the Sponsoring Organization contemporaneously with the issuance of this Certificate, as the same may be amended, modified or extended from time to time by further written agreement of the parties, which by this reference shall be incorporated in and become a part of the Master Policy and this Certificate.

AIDS: Acquired Immune Deficiency Syndrome, as that term is defined by the United States Centers for Disease Control.

Amateur Athletics: An amateur or other non-professional sporting, recreational, or athletic activity that is organized, sponsored and/or sanctioned, and/or involves regular or scheduled practices, games and/or competitions. This definition does not include athletic activities that are non-contact and engaged in by the Insured Person solely for recreational, entertainment or fitness purposes or interscholastic sports.

ARC: AIDS related complex, as that term is defined by the United States Centers for Disease Control.

Assured: Council on International Educational Exchange (CIEE)

Baggage: All types of luggage and baggage owned by and in the possession, custody and control of the Insured Person, including without limitation suitcases, duffle bags, backpacks, carryalls, flights bags, handbags, knapsacks, garment bags, overnight bags, satchels and other travel bags, and including clothing and other related non-Valuable personal items which are owned by the Insured Person and contained in any such Baggage.

Calendar Year: The twelve months beginning on January 1 and ending on December 31, annually.

Chronic Illness: An Illness which lasts more than one hundred and twenty (120) days or recurs more than one time in a one hundred and twenty (120) day period beginning on the initial date of Treatment thereof.

Coinsurance: The payment of Eligible Medical Expenses at the percentage specified in the Schedule of Coverage and exclusive of the Deductibles.

Company: The “Company”, as referred to in the Master Policy and the Agreement to Provide Insurance, is International Exchange Travel Insurance Company, headquartered in South Burlington, Vermont. This insurance and its risks are underwritten by the Company as the insurer and carrier, and the Company is solely obligated and liable for the coverages and benefits provided by this insurance.

Copay: The amount that must be paid by the Insured Person at the time services are rendered by a Provider. Copay amounts are the responsibility of the Insured Person

Custodial Care: Those types of Treatment, care or services, wherever furnished and by whatever name called, that are designed primarily to assist an individual.

Deductible(s): The dollar amount(s) of Eligible Medical Expenses, specified in the Declaration and/or the Schedule of Benefits/Limits that an Insured Person must pay per Illness or Injury per Period of Insurance prior to receiving benefits under this insurance, and exclusive of Coinsurance.

Dental Treatment: Treatment or supplies relating to the care, maintenance or repair of teeth, gums or bones supporting the teeth, including dentures and preparation for dentures.

Durable Medical Equipment: Durable Medical Equipment consists of the following items: a standard basic hospital bed and/or a standard basic wheelchair.

Educational or Rehabilitative Care: Care for restoration (by education or training) of one’s ability to function in a normal or near normal manner following an Illness or Injury. This type of care includes, but is not limited to, vocational or occupational therapy, and speech therapy.

Effective Date of Coverage: The date an Insured Person is first entitled to receive benefits under this insurance.

Eligible Medical Expenses: As defined in the Description of Medical benefits.

Emergency: A medical condition diagnosed by a Physician, which meets all of the following criteria: (1) there is present a severe or acute symptom requiring immediate care and the failure to obtain such care could reasonably result in serious deterioration of your condition or places your life in jeopardy; (2) the severe or acute symptom occurs suddenly and unexpectedly; and (3) the severe or acute symptom occurs while you are covered under this policy.

Extended Care Facility: An institution, or a distinct part of an institution, which is licensed as a Hospital, Extended Care Facility or rehabilitation facility by the state or country in which it operates; and is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a Physician; and provides each patient with active Treatment of an Illness or Injury. Extended Care Facility does not include a facility primarily for rest, the aged, Substance Abuse, Custodial Care, nursing care, or for care of Mental or Nervous Disorders or the mentally incompetent.

Hazardous Sports: Any activities such as skydiving, parachuting, hang gliding, glider flying, parasailing, sail-planing, bungee jumping, mountaineering activities (up to 4500 meters and with proper use of ropes and guides), scuba diving (to depths no greater than 50 meters), spelunking, piloting and aircraft (except commercial): and travel on a motorcycle, 4-wheel all terrain vehicle (ATV), snowmobile, jet ski or ski cycle.

HIV: Human Immunodeficiency Virus, as that term is defined by the United States Centers for Disease Control.

Home Country: The country of which the Insured Person is a citizen or national; or maintains his/her residence or usual place of abode; or the country of which the Insured Person is the possessor of a validly issued passport.

Home Health Care Agency: A public or private agency or one of its subdivisions, which operates pursuant to law; and is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation and Treatment prescribed by a Physician.

Home Nursing Care: Services provided by a Home Health Care Agency and supervised by a Registered Nurse, which are directed toward the personal care of a patient provided always that such care is Medically Necessary and not primarily for Custodial Care or rehabilitative purposes.

Hospital: An institution which operates as a Hospital pursuant to law; and is licensed by the state or country in which it operates; and operates primarily for the reception, care, and Treatment of sick or injured persons as Inpatients; and provides 24-hour nursing service by Registered Nurses on duty or call; and has a staff of one or more Physicians available at all times; and provides organized facilities and equipment for diagnosis and Treatment of acute medical, surgical or mental/nervous conditions on its premises; and is not primarily a long-term care facility, Extended Care Facility, nursing, rest, Custodial Care, or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment.

Hospitalization: Confined and/or treated in a Hospital as an Inpatient.

Host Country: The country or countries other than the Home Country that the Insured Person is traveling to/in.

Illness: A sickness, disorder, illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. Illness does not include learning disabilities, attitudinal or disciplinary problems. All related conditions and recurrent symptoms of the same or related condition will be considered one Illness.

Injury: Bodily injury resulting from an Accident.

Inpatient: A person who is an overnight resident patient of a Hospital, using and being charged for room and board.

Insured Person: A Participant, on and after his/her Effective Date of Coverage and prior to his/her termination date, who has been properly listed on a census submitted to the Company by the Sponsoring Organization in accordance with the Terms of the Agreement to Provide Insurance, and for whom the proper Premium has been timely paid by the Sponsoring Organization.

Intensive Care Unit: A cardiac care unit or other unit or area of a Hospital that meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations for Special Care Units.

Investigational, Experimental, or for Research Purposes: Any procedures, Treatment or supplies that by nature or composition deviate from, or are used or applied in a way which deviates from, generally accepted standards of current medical practice.

Maximum Limit: The cumulative total dollar amount of all available benefit payments and/or reimbursements available to an Insured Person under this insurance during the Insured Person’s lifetime, which shall not exceed $100,000.00. When the Maximum Limit is reached, no further benefits, reimbursements or payments will be available under this insurance.

Medically Necessary/Medical Necessity: A Treatment, service, medicine or supply which is necessary and appropriate for the diagnosis or Treatment of an Illness or Injury based on generally accepted standards of current medical practice, as determined by the Company. By way of example but not limitation, a service, Treatment, medicine or supply will not be considered Medically Necessary or a Medical Necessity if it is provided or obtained only as a convenience to the Insured Person or his/her provider; and/or if it is not necessary or appropriate for the Insured Person’s Treatment, diagnosis or symptoms; and/or if it exceeds (in scope, duration or intensity) that level of care which is needed to provide safe, adequate, and appropriate diagnosis or Treatment.

Mental or Nervous Disorder: Any disease or condition, regardless of whether the cause is organic, that is classified as a Mental Disorder in the current edition of the International Classification of Diseases, published by the U. S. Department of Health and Human Services or is listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.

Negotiated Charge: The maximum charge a Preferred Care Provider has agreed to make as to any service or supply for the purpose of the benefits under the plan.

Newborn: An infant from the moment of birth through the first thirty-one (31) days of life.

Other Coverage: Other insurance, membership benefit, workers’ or workplace compensation coverage, government program, reimbursement or indemnification coverage, right of contribution, recoupment or recovery, contract, or any other third-party obligation or provision of benefits which would be available to provide such benefit or to pay or reimburse or provide indemnity for any claim.

Outpatient: A person who receives Medically Necessary Treatment by a Physician or other healthcare provider that does not require an overnight stay in a Hospital.

Participant: A person who is actively participating and properly enrolled as a student in one of the Council on International Educational Exchange student exchange programs as listed and identified in the Agreement to Provide Insurance.

Period of Insurance: With respect to each Insured Person, the period of coverage and available benefits under this insurance plan, beginning on the Insured Person’s Effective Date of Coverage and ending on the date of termination of coverage under the Terms of this insurance; provided, however, that there shall be no coverage or available benefits under this insurance plan during, and no Period of Insurance shall be deemed or construed to include, any period of time an Insured Person does not fully meet the definition of “Participant” and/or any period of time any Participant or Insured Person is physically located in his/her Home Country for any reason.

Personal Papers: Credit cards, checkbooks, airline tickets, passports, visas, birth certificates, negotiable securities, commercial and administrative documents, and other personal papers owned by and titled in the name of an Insured Person and in the possession, custody and control of the Insured Person during the Period of Insurance

Physician: A duly licensed practitioner of the medical arts. A Physician must be currently licensed by the state or country in which the services are provided, and the services must be within the scope of that license.

Pre-certification/Pre-certify: A general determination of Medical Necessity, only, made by the Company in reliance and based upon the completeness and accuracy of the information provided by the Insured Person and/or the Insured Person’s healthcare providers, guardians and/or proxies at the time thereof. Pre-certification is not an assurance, authorization, pre-authorization, or verification of coverage, a verification of benefits, or a guarantee of payment. See Section E, above, for further details.

Pre-existing Condition: Any injury, sickness or condition that was diagnosed, treated or with reasonable medical certainty, existed at the Effective Date of Coverage for the Insured Person or at any time within twelve months prior to the covered person’s Effective Date of Coverage whether or not previously symptomatic or known.

Premium: The premium payments required to effectuate and maintain the Sponsoring Organization’s and the Insured Persons’ respective insurance coverage and benefits under this insurance, in the proper amounts and at the times (“Due Dates”) established by the Company in its sole discretion from time to time and as set forth in the Agreement to Provide Insurance.

Reasonable Charge: Only that part of a charge which is reasonable is covered. The Reasonable Charge for a service or supply is the lowest of:

The provider’s usual charge for furnishing it;
The charge the Company determines to be appropriate; based on factors such as the cost of providing the same or a similar service or supply and the manner in which charges for the service or supply are made;
The charge the Company determines to be the prevailing charge level made for it in the geographic area where it is furnished.

In some circumstances the company may have an agreement either directly or indirectly through a third party with a provider which sets the rate that the Company will pay for a service or supply. In theses instances in spite of the methodology described above the Reasonable Charge is the rate established in such agreement.

Registered Nurse: A graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters “R.N.” after his or her name.

Related Third Person: Any individual or natural person who is a Relative of the Insured Person, a traveling companion of the Insured Person or a Relative of such traveling companion, and any other person, individual or family member with whom the Insured Person is residing or being hosted.

Relative: Parent, guardian, spouse, son, daughter, or immediate family member of an Insured Person.

Rider: Any exhibit, schedule, attachment, amendment, endorsement, rider or other document attached to, issued in connection with, or otherwise expressly made a part of or applicable to, the Master Policy, the Certificate, or the Agreement to Provide Insurance, as the case may be.

Sponsoring Organization: The Council on International Educational Exchange, Inc., headquartered in Boston, MA.

Substance Abuse: Alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency.

Surgery or Surgical Procedure: An invasive diagnostic or surgical procedure; or the Treatment of Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.

Terms: Terms, provisions, conditions, definitions, limits, sub-limits, limitations, wordings, restrictions, qualifications and/or exclusions.

Terrorism: The systematic or planned use of violence, fear, or the threat of violence in order to intimidate a population or government, especially as a means of coercion or to obtain a granting of any demand.

Third Person: Any individual, natural person, or other legal entity or person, other than the Insured Person or a Related Third Person.

Totally Disabled/Total Disability: The inability, due to Illness or Injury, of an individual to perform all of the substantial and material duties of their regular employment or occupation.

Treatment/Treated: Any and all undertakings, services and/or procedures rendered or employed with respect to the management and/or care of an Insured Person for the purpose of identifying, diagnosing, treating, curing, resolving, preventing, monitoring, attending to, controlling and/or combating any Illness or Injury or the symptoms or manifestations thereof, including without limitation: verbal or written advice, consultation, examination, discussion, diagnostic or laboratory testing or evaluation of any kind, pharmacotherapy or other medication, and/or Surgery.

Treatment Period: The one hundred and twenty (120) day period of time for which benefits shall be reimbursable or payable for Eligible Medical Expenses incurred with respect to an Injury or Illness. At the end of the Treatment Period, no further benefits will be available for such an Injury or Illness, whether or not additional Eligible Medical Expenses are incurred with respect thereto.

Usual, Reasonable and Customary: The most common charge for similar Treatment, services, medicines, or supplies within the area in which the charge being reviewed or considered for reimbursement or coverage is incurred, and so long as those charges are reasonable, all as determined by the Company in its sole discretion. In determining whether a charge is Usual, Reasonable and Customary, the Company may consider one or more of the following factors, without limitation: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or service as compared to the length of time required to perform other similar services; the severity or nature of the Illness or Injury being Treated; the amount charged for the same or comparable Treatment, services, medicines or supplies in the locality; the amount charged for the same or comparable Treatment, services, medicines or supplies in other parts of the country; the cost to the provider of providing the Treatment, service, medicine or supply; and such other factors as the Company, in the reasonable exercise of its discretion, determines are appropriate.

Valuables: Items of personal property and other objects (other than Baggage and Personal Papers) having a value in excess of $175.00, which may include jewelry, cameras, video cameras, leather goods, watches, computer equipment, sound recorders and video or DVD players; provided however, that the term “Valuables” shall expressly not include any sports or sporting equipment, components, or supplies, mobile telephones or other personal communication devices, MP3 players, IPods, portable DVD players or other similar personal electronic devices.