StudentSecure Travel Insurance

Schedule of Benefits and Limits
Benefit Select Budget Smart
Certificate Period Maximum $300,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child)
$250,000 (Participant)
No dependent coverage
$200,000 (participant)
No dependent coverage
Maximum Benefit per Injury or Illness $300,000 (Participant)
$ 50,000 (Spouse)
$ 50,000 (Child)
$250,000 (Participant)
No dependent coverage
$200,000 (participant)
No dependent coverage
Deductible $25 per injury or illness within the PPO, outside the U.S. or student health center; otherwise $50 per injury or illness $45 per injury or illness within the PPO, outside the U.S. or student health center; otherwise $90 per injury or illness $50 per injury or illness within the PPO, outside the U.S. or student health center; otherwise $100 per injury or illness
Coinsurance
Claims incurred in US
Underwriters will pay 80% of the next $5,000 of Eligible Expenses after the Deductible, then 100% to the Certificate Period Maximum

*For charges incurred within the PPO or at a Student Health Center, coinsurance will be waived.
Underwriters will pay 80% of the next $25,000 of Eligible Expenses after the Deductible, then 100% to the Certificate Period Maximum Underwriters will pay 80% of eligible expenses after the deductible
Coinsurance
Claims incurred oustide of US
After the Deductible, Underwriters will pay 100% of Eligible Expenses to Certificate Period Maximum
Hospital Room & Board Average Semi-private room rate, including nursing services
Local Ambulance Up to $750 per Injury / Illness if Hospitalized as Inpatient Up to $500 per Injury / Illness if Hospitalized as Inpatient Up to $300 per Injury / Illness if Hospitalized as Inpatient
Intensive Care Unit Usual, Reasonable, and Customary charges
Hospital pre-certification penalty 50% of eligible medical expenses
Outpatient treatment Usual, Reasonable, and Customary charges
Outpatient Prescription Drugs 50% of Actual Charge
Mental Health Disorders Outpatient or inpatient: 80% within the PPO, 60% out of network. Maximum 30 days of coverage.

(Coverage includes drug abuse or alcohol abuse. Treatment must not be obtained at a student health center.)
Outpatient: $50 maximum per day, $500 maximum lifetime

Inpatient: Usual, reasonable, and customary charges to $10,000 maximum lifetime

(Coverage includes drug abuse or alcohol abuse. Treatment must not be obtained at a student health center.)
Outpatient: $50 maximum per day, $500 maximum lifetime

Inpatient: Usual, reasonable, and customary charges to $5,000 maximum lifetime
Dental Treatment due to Accident $250 Maximum per tooth
$500 Maximum per Certificate Period
No coverage
Dental Treatment to alleviate pain $100 maximum per certifi cate period. Not subject to deductible or coinsurance. No coverage
Pre-existing condition 6-month waiting period 12-month waiting period $25,000 lifetime maximum for eligible medical expenses for the acute onset of pre-existing condition only
Maternity Care for a Covered Pregnancy 80% up to certificate period maximum within the PPO; 60% up to certificate period maximum outside the PPO 80% up to $5,000 within the PPO; 60% up to $5,000 outside the PPO No coverage
Routine Nursery Care of Newborn $750 Maximum per Certificate Period $250 Maximum per Certificate Period No coverage
Therapeutic Termination of Pregnancy $500 Maximum per Certificate Period
Physical Therapy & Chiropractic Care Maximum $50 per visit per day Maximum $50 per visit per day Maximum $25 per visit per day
Intercollegiate, interscholastic, intramural, or club sports $5,000 Maximum per Injury / Illness
Medical Expenses only
$3,000 Maximum per Injury / Illness
Medical Expenses only
No coverage
Terrorism $50,000 Maximum Lifetime Limit No coverage
Emergency Medical Evacuation
Not subject to deductible or coinsurance.
Up to the certificate limit (participant)
$50,000 Lifetime (Spouse)
$50,000 Lifetime (Child)
Up to the certificate limit (participant)

No dependent coverage
$25,000 lifetime (participant)

No dependent coverage
Emergency Reunion $2,500 Lifetime $1,000 Lifetime $1,000 lifetime
Accidental Death & Dismemberment Principal Sum – lifetime maximum
$25,000 (Participant)
$10,000 (Spouse)
$5,000 (Child)
No coverage
Repatriation of Remains $25,000 maximum
(not subject to deductible or coinsurance)
$25,000 maximum
(not subject to deductible or coinsurance)
$7,500 maximum
(not subject to deductible or coinsurance)

All benefits are per covered individual and for covered conditions. All benefits, except Accidental Death & Dismemberment, are subject to the Deductible and Coinsurance. Limits apply to all benefits.