Today’s Lecture U of I Student Injury and Sickness Insurance Plan Undergraduate Plan Benefit Provisions General Limitations Reduction of Benefits Examples

Hospital Expense Benefits Room and Board Not to exceed average semi-private room rate $100 deductible applies here Hospital Expenses Operating room, drugs, x-rays, laboratory tests, medical supplies while confined

Hospital Expense Benefits Example Hospitalized for 10 days for meningitis Room and board $500/day (ave. semi-private) Room and board$5000 Drugs $2500 Lab Tests $5000 Medical Supplies $2000 Total hospital expenses $14,500

Hospital Expense Benefits Example You pay $100 deductible Of the remaining $14,400, they pay $8000 (80% of the next $10,000) plus $4400 (all of the amount over $10,100) Amount payable by Student Health Plan: $12,400 You pay $2,100 ($100 deductible plus 20% of $10,000)

Durable Medical Equipment Only covered for accidental injury: Splints, casts, crutches and braces Accidental injury must have occurred while insured

Dental Lower of: 80% of Usual and Customary or 80% of Actual Charge Deductible applies (if student) Covered only for: Injury to Sound, Natural Teeth The removal of bony impacted wisdom teeth TMJ (Temporo-Mandibular Joint) disorder

General Exclusions and Limitations Pages Addiction, such as nicotine addiction 6Cosmetic procedures, except cosmetic surgery required to correct an injury... 7Dental treatment except as specifically provided in the Schedule of Benefits 14Injury caused by or resulting from the use of alcohol, illegal drugs or any drugs or medicines not taken in the recommended dosage... 16Injury sustained participating in interscholastic or professional sport, contest or competition (including traveling or practicing) 18 Participation in a riot or civil disorder; commission of or attempt to commit a felony 23Routine physical exams... 26Suicide or attempted suicide while sane or insane (including drug overdose) or intentionally self inflicted injury

Sports Injuries Page 7 “This plan covers injuries incurred while participating in intercollegiate, club and intramural sports, limited to $75,000.” Page 17 – Intercollegiate Sports Benefit “Insured student athletes who are members of and are participating in intercollegiate sports sponsored by the Policyholder are covered for sports injury.”

Example While attempting to rob a bank, you (a student) accidentally shoot yourself in the foot. The police easily catch you as you are trying to hop away. They take you to the emergency room on the way to jail. You are billed $500 for the emergency room. How much does the U of I Student Plan pay? A)0 B)240 C)280 D)350 E)None of the above

Reduction of Benefits Applies when covered person has other valid coverage, specifically: Hospital or Medical Insurance Group Insurance Auto Medical Payments Employee Benefit Plan Does not include third party liability coverage

Calculating the Reduction of Benefits Initial Benefit Payment Benefit is reduced by 50% Statement “No more than 100% of the eligible expenses are compensable between this Plan’s benefits and the benefits of any Other Valid Coverage…”

Calculating the Reduction of Benefits If the Initial Benefit Payment (under U of I plan) plus other benefits are less than 100% of eligible expenses, then an Additional Benefit Payment will be made. Additional Benefit Payment = the lower of: Normal Benefit - Initial Benefit Payment or 100% of Eligible Expenses - (Initial Benefit Payment + Other Valid Coverage)

Example You incur $5200 in Outpatient Miscellaneous Illness and Accident Expenses during the year. Eligible Expenses$5200 Normal Benefit 4040 [( ) x.8 = $4040] Other group insurance pays $2700.

Example - (Cont.) Initial Benefit Payment.5 x $4040 = 2020 Other Valid Coverage = 2700 Total 4720 Additional Benefit Payable Lower of = = 480

Example - (Cont.) Total Benefit Payable Initial Benefit Payment2020 Additional Benefit Payment Insured receives $2500 from U of I Plan plus $2700 from the other coverage for a total of $5200, the total expenses.

Subrogation This policy has the right to recover any benefits paid if a third party is liable for the sickness or injury. (Page 18) Example Plan pays $25,000 to a student injured in an automobile accident. The total medical bills were $30,000. If the student can collect a bodily injury award of $75,000 from the driver of the vehicle that covers all the medical bills plus pain and suffering, the plan is entitled to recover the $25,000 that it paid.

Insurance Premiums by Year Undergraduate Plan