today’s lecture u of i student injury and sickness insurance plan undergraduate plan
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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 - PowerPoint PPT PresentationTRANSCRIPT
Today’s LectureU of I Student Injury and Sickness
Insurance PlanUndergraduate 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 BenefitsExample
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 BenefitsExample
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
DentalLower 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 Exclusionsand Limitations
Pages 14-152 Addiction, such as nicotine
addiction6 Cosmetic procedures, except
cosmetic surgery required to correct an injury...
7 Dental treatment except as specifically provided in the Schedule of Benefits
14 Injury caused by or resulting from the use of alcohol, illegal drugs or any drugs or medicines not taken in the recommended dosage ...
16 Injury 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
23 Routine physical exams ...26 Suicide 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.”
ExampleWhile 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) 0B) 240C) 280D) 350E) 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
[(5200-150) 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
4040 - 2020 = 2020
5200 - 4720 = 480
Example - (Cont.)
Total Benefit Payable
Initial Benefit Payment 2020
Additional Benefit Payment 480
2500
Insured receives $2500 from U of I Plan plus $2700 from the other coverage for a total of $5200, the total expenses.
SubrogationThis 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 YearUndergraduate Plan
0
100
200
300
400
500
600
700
800
1987-88
1990-91
1993-94
1996-97
1997-98
1998-99
1999-00
2000-01
2001-02
2002-03
2004-05
2005-06
2006-07
2007-08
StudentSpouseChild
Insurance Premiums by YearUndergraduate Plan
020406080
100120140160180
1987-88
1990-91
1993-94
1996-97
1997-98
1998-99
1999-00
2000-01
2001-02
2002-03
2004-05
2005-06
2006-07
2007-08
Student