Description of Medical Benefits
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Payment will be made as allocated herein, for Covered Medical Expenses incurred for any illness or injury while insured under the Policy. Please refer to your Confirmation of Insurance Coverage document for the maximum lifetime benefit for your Policy.

The payment of any Copays and the balance above any Coinsurance amount, and any medical expenses not covered are the responsibility of the Insured Person. To maximize your savings and reduce out-of-pocket expenses, we recommend that you select a Preferred Provider. It is to your advantage to utilize a Preferred Provider because significant savings can be achieved from the substantially lower rates these providers have agreed to accept as payment for their services. Non-Preferred Care is subject to the Reasonable Charge allowance maximums. Any charges in excess of the Reasonable Charge allowance are not covered under the Plan.

The following benefits are subject to the imposition of Policy limits and exclusions.

 

Summary of Benefits for CIEE Insurance Coverage

Provider Network

Aetna Preferred Provider Network with access to over 672,000 health care service providers nationwide

 

Claims Administrator

Aetna Student Health

 

Copays

Preferred or Non Preferred Care

     Outpatient - $50 per visit

     Inpatient or Emergency Room - $100 per visit

 

Coinsurance

Preferred Care – 100% of Negotiated Charge

Non Preferred Care – 80% of Reasonable Charge

 

Maximum Limit

Please refer to your Confirmation of Insurance Coverage document

 

Treatment Period

120 days per Injury or Illness

 

Hospital Room & Board

Up to the average semi-private room rate, including nursing service after $100 copay

 

Intensive Care Unit

Up to the average semi-private room rate, including nursing service after $100 copay

 

Physical Therapy

Outpatient benefits are limited to 1 visit per day

 

Physician’s Visits

Benefits are limited to 1 visit per day after $50 copay not applicable to Surgery

 

Eligible Medical Expenses

Preferred Providers:  100% of Negotiated Charge

Non Preferred Providers: 80% of Reasonable Charge; 100% of Negotiated Charge if Insured Person lives more than 50 miles from a Preferred Provider

 

Prescription Drugs

$20 copay per prescription per 30 day supply

 

Temporomandibular Joint Disorder and/or Craniomandibular Disorder

Up to $5,000 lifetime maximum benefit

 

Dental Treatment

Relief of sudden and unexpected pain to sound natural teeth: Up to $350 maximum

Injury: Up to $500 per accident, including fracture of the jaw

 

Pre-certification

50% Reduction of Eligible Medical Expenses if Pre-certification requirements are not met or if the expenses are not Pre-certified

 

Urgent Travel Expense

Up to $500 for transportation to home country in the event of death of father, mother, brother or sister

 

Emergency Medical Evacuation Expenses

 

Up to $15,000 Maximum Limit.

Emergency Reunion

Up to $15,000 Maximum Limit

Return of Mortal Remains

Up to $15,000 Maximum Limit

 

Accidental Death and Dismemberment

 

Accidental Death: $8,500

Dismemberment: Up to $85,000 Maximum Limit
Baggage  

 

Loss or theft of Baggage

Loss or theft of Valuables

Loss or theft of Personal Papers

 

Up to $1,500 per Period of Insurance

Up to $350 per Period of Insurance

Up to $500 per Period of Insurance

 
Legal Assistance  

 

Attorney Fees

 

 

 

Advance of Bail

 

Up to $20,500

Sublimit: Up to $500 for initial consultation expenses in the event of a legal summons or threat of lawsuit, or other notice of a third-party claim in regard to personal injury or property damage liability

Up to $8,500

 
Personal Liability  

 

Injury to a third Person

Damage to Third Person’s Property

Damage to related Third Person’s property

 

Up to $100,000

Up to $100,000

Up to $2,500, subject to a $100 deductible