If a Covered Person incurs expenses while insured under the Policy due to an Injury or a Sickness, the Insurer will pay the Reasonable Expenses for the Covered Medical Expenses listed below. All Covered Medical Expenses incurred as a result of the same or related cause, including any Complications, shall be considered as resulting from on Sickness or Injury. The amount payable for any one Injury or Sickness will not exceed the Maximum Benefits of $1,000,000 per Lifetime, $250,000 per Policy Year, $250,000 per Injury or Sickness for the Eligible Participant and the Eligible Dependent. Benefits are subject to the Deductible Amount, Coinsurance and Maximum Benefits stated in the Schedule of Benefits, specified benefits and limitations set forth under Covered Medical Expenses, the General Policy Exclusions, the Pre Existing Condition Limitation, the Recognized Student Health Center Provision and to all other limitations and provisions of the Policy.
When using non-PPO health care providers, insured persons are responsible for any difference between the covered expenses and actual charges, as well as any percentage co-payment.
1 All Physician Visit Copayments for an Injury or Sickness are waived if treatment is received at Recognized Student Health Center or if the initial treatment for an Injury or Sickness is received at Recognized Student Health Center. If there is a charge for visits to, or medical services, treatments and supplies received from, a Recognized Student Health Center for an Injury or a Sickness, benefits for those visits, medical services, treatments and supplies will be paid at 100% of Reasonable Expenses with no Copayment or Deductible. If the Recognized Student Health Center is not able to treat the Covered Person, it will refer the Covered Person to a Preferred Provider. If the Covered Person uses the Preferred Provider, medical benefits are paid according to the “Inside PPO” schedule. If the Covered Person chooses not to use the Preferred Provider, medical benefits are paid according to the “Outside PPO” schedule.
2 Inpatient Hospital Services and Hospital and Physician Outpatient Services consist of the following: Hospital room and board, including general nursing services; medical and surgical treatment; medical services and supplies; Outpatient nursing services provided by an RN, LPN or LVN; local professional ground ambulance services to and from a local Hospital for Emergency Hospitalization and Emergency Medical Care, X-rays; laboratory tests, prescription medicines; artificial limbs or prosthetic appliances, including those which are functionally necessary; the rental or purchase, at the Insurer’s option, of durable medical equipment for therapeutic use, including repairs and necessary maintenance of purchased equipment not provided for under a manufacturer’s warranty or purchase agreement. The Insurer will not pay for Hospital room and board charges in excess of the prevailing semi private room rate unless the requirements of Medically Necessary treatment dictate accommodations other than a semi private room.
3 The Insurer will pay the actual expenses incurred as a result of pregnancy, childbirth, miscarriage, or any Complications resulting from any of these, except to the extent shown in the Schedule of Benefits. Conception must have occurred while the Covered Person was insured under the Policy.
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