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2011-2012 Student Accident & Sickness Insurance Plan

Pat Delplanche | Safety & Risk Services | 971-722-2809

This information is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the policy issued in Oregon under form number AH-10331-OR. Complete details may be found in the policy on file at your School’s office. The policy is subject to the laws of the state in which it was issued. Please keep the brochure as a reference. Information on this page is copied from the brochure. The enrollment form is in the brochure. Please allow 3 weeks to receive your Insurance Verification card.

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Medical Expense Benefit

$50,000 Maximum Benefit per Covered Accident or Sickness. Payment of benefits will be made only for a Sickness or an Accident that occurs during the period of time for which coverage has been purchased.

Extension of Benefits: Benefits will be extended under the Policy up to 3 months if, on the date insurance would otherwise end, and the Covered Person has incurred covered Expenses and is under a Doctor’s care for an Injury or Sickness Covered by the Policy. Benefits will be extended for up to 6 months if the Covered Person is Totally Disabled due to a Covered Injury or Sickness. This provision will apply only if the required premium is paid. Any benefits payable under this provision will not exceed the benefit maximums shown in the Schedule of Benefits.

Coordination of Benefits

Should a Covered Person or a dependent of a Covered Person have health care coverage other than that provided under this Plan, benefits under this Plan will be coordinated with those benefits payable under the other health care coverage (subject to provisions contained in the Policy). This provision applies only to the Medical Expense Benefit.

Premiums (rates are per term)

	Student Only	Spouse / Domestic Partner	Each Child
Accident Only	$89	$118	$65
Accident & Sickness: All Ages	$234	$328	$137

Schedule of Benefits

We will pay benefits only for Covered Injuries sustained or Covered Sickness while insured under this School Year’s plan. The Covered Person must seek Treatment within 12 months after the date of the Accident or the Sickness. The Company will pay Usual and Customary medical and dental charges, as defined by the Policy, subject to exclusions, requirements and limitations, for necessary supplies and services are payable, per Covered Injury or Sickness, as follows: (We do not pay for a service or supply unless it is Medically Necessary and listed in the schedule of benefits, below.)

Maximum Payable Per Condition	$50,000
Maximum Payable for Motor Vehicle Injury	$5,000
Deductible Per Condition	$100
Hospital Room & Board (Semi-private room rate)	100%
Inpatient Hospital Miscellaneous Charges	100% up to $1,500
Intensive Care Unit	100%
Outpatient Emergency (Room & Supplies) incurred within 72 hours of an emergency	100% up to $300
Outpatient Surgical (Room & Supplies)	100% up to $1,000
Surgeon Services	80% up to $2,000
Assistant Surgeon Services	80% up to $2,000
Anesthesiologist Services	20% of Surgeon’s Allowance
Doctor Non-Surgical Treatment/Exam* (includes breast, pelvic and pap smear exam for women age 18-64 if ordered by a Doctor)	$40 Initial Visit; $25 Each Follow Up; $75 Consultation
Physiotherapy (includes related office visit) When prescribed by a Doctor	100% up to $25/Visit 10 Visit Maximum
X-Ray Examinations (includes reading)	100% to $150 per Set
Diagnostic Imaging* - MRI/Cat Scan (Mammogram for women age 40 or older)	100% to $500
Laboratory Procedures	100% up to $200
Registered Nurse Services	100%
Rehabilitative Braces and Appliances	100% up to $100
Ambulance (from site of emergency to hospital)	100% up to $500
Outpatient Prescription Drugs (Prescription contraceptives, and non-prescriptive elemental enteral formula for home use if: Medically Necessary for the Treatment of severe intestinal malabsorption; ordered by a Doctor; and comprises the sole source of nutrition.)*	100% up to $300
Dental Services, including dental x-rays, for Treatment to teeth due to a Covered Accident	100% up to $200 per Tooth Maximum Benefit $1,000

*Applies to Accident & Sickness Benefits only.

Accidental Death and Dismemberment Benefits (for students only)

If a Covered Person’s Injury results in any of the following losses specified below, within 180 days of a Covered Accident, the Company will pay the amount shown for that loss. The loss must result solely and independently from all other causes from a Covered Accident. The Company will pay only one benefit, the largest, for all losses due to the Covered Accident.

Payment of benefits will be made only for accidental Injuries caused by Accidents which occur during the period of time for which coverage has been purchased. The Accident-Only plans do not include benefits for Sickness.

Pre-Existing Condition Limitation:

Benefits will not be paid for a pre-existing condition for which a Covered Person received medical Treatment, care, diagnosis, or advice within six consecutive months prior to the effective date of his or her coverage. This limitation will not apply if the Covered Person has not received such Treatment, care, or advice within six consecutive months while covered by the Policy, or if the Covered Person has been covered by this Policy for more than six consecutive months. Medical Treatment includes, but is not limited to, prescription medication. A new six- month pre-existing condition limitation cannot be imposed in subsequent School Years after the first, unless there is a separation period of more than one School term or semester break.

Continuous Coverage: Continuous coverage will be granted from year to year provided any previous coverage was continuous to a date not more than one School term or semester break prior to the effective date of the new coverage. This coverage will be afforded to Covered Person’s insured by any previous insurance plan provided this continuous coverage stipulation is met. If this continuous coverage stipulation is not met, any pre-existing condition excluded under this provision shall not qualify for coverage under this Student Accident and Sickness Program until six months from the effective date of coverage.

Exclusions

No benefits will be paid for:

1. Intentionally self-inflicted Injury.
2. Suicide or attempted suicide.
3. War or any act of war, whether declared or not.
4. Service in the military, naval or air service of any country.
5. Participation in a riot or civil disorder; commission of, or attempt to commit, a felony.
6. Services provided normally without charge by the Health Services of the Policyholder or by any other person employed or retained by the Policyholder and the Student health fee unless specifically provided under the Policy.
7. Injury caused by, attributed to or resulting from the Covered Person being legally intoxicated as defined by the laws of the state in which the Accident occurs or use of illegal drugs, or any drugs or medicines that are not taken in the dosage or for the purpose prescribed by the Covered Person’s Doctor.
8. Injury resulting from playing, practicing, participating, conditioning or traveling to or from any contest or competition of intercollegiate or interscholastic sports sponsored by the School, or any professional or semi- professional sport.
9. Injury or Sickness for which benefits are payable under any Workers’ Compensation or Occupational Disease Law or Act or similar legislation.
10. Any Elective Surgery or Elective Treatment.
11. Routine physical examinations and routine testing: preventative testing or Treatment: preventative medicines or vaccines except as specifically set forth in Covered Expenses.
12. Dental Treatment, except for Accidental Injury to sound, natural teeth as specifically provided under the Policy.
13. Eye examinations; prescriptions or fitting of eyeglasses and contact lenses.
14. Hearing examinations and hearing aids.
15. Routine newborn baby care, well baby nursery care and related Doctor’s charges.
16. Skydiving, parachuting, hang gliding, glider flying and bungee jumping.

This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit us from providing insurance, including but not limited to, the payment of claims.

Facility of Payment

Whenever payments that should have been made under the Policy are made by any other policy, the Company reserves the right, at their sole discretion, to pay over to any plan making such other payments, any amounts the Company determines are warranted in order to satisfy the intent of this provision. The amounts paid are considered benefits paid under the Policy and, to the extent of such payments, the Company shall be fully discharged from liability under the Policy. In no event will the Company pay more than the benefits payable under the Policy for all policies providing the same or similar benefits issued to the Policyholder and underwritten by the Company.

Eligibility

All full-time Students of the Portland Community College who are enrolled continuously for 9 credit hours or more per term are eligible for insurance. A Covered Person’s eligible Dependents may be insured. No person may be eligible for insurance as both a Covered Person and a Dependent at the same time.

Eligible Dependents are the Covered Person’s lawful spouse, domestic partner, or unmarried child from the moment of birth to age 19 who are chiefly dependent on the Insured for support. For an Insured Dependent child who reaches the age limit and is incapable of self-sustaining employment because of a mental or physical handicap, insurance may be continued provided we receive notice and adequate proof within 31 days of the date coverage would otherwise terminate. Adopted children are eligible for coverage from the date of placement with the Insured, provided, an enrollment form is received within 31 days of placement. Coverage will cease if placement is disrupted prior to legal adoption and the child is removed from the Insured's home.

If a Covered Person acquires a Dependent after the effective date of his or her coverage, the Dependent will be eligible for coverage on the date they qualify as a Dependent. Dependent Child includes a legally adopted child including a child who placed in the Covered Person’s home and the Covered Person’s newborn child.

Eligible persons may be insured under this Policy subject to the following:

1. Payment of premium as set forth in the brochure; and
2. Enrollment Form (in the brochure) to the Administrator for such coverage.

Effective Date of Insurance

Insurance under the Policy shall become effective on the latest of the following dates:

1. The Effective Date of the Policy; or
2. The date premium is received by the Administrator.
3. The date the completed enrollment form, is received by the Administrator.

Dependent coverage will not be effective prior to that of the Covered Person.

Coverage becomes effective for a newborn child automatically from the moment of birth, and automatically ends when the child is 31 days old, unless the Covered Person makes a request to continue coverage for that child and pay the required premium, when due. Adopted children will be covered on the same basis as a newborn child from the date the child is placed for adoption with the Covered Person. Coverage will cease on the date the child is removed from placement. Coverage will include the necessary care and Treatment of medical conditions existing prior to the date of placement.

Termination of Insurance

The coverage provided with respect to the Insured Student shall terminate on the earliest of the following dates:

1. The last day of the period through which the premium is paid;
2. The date the Policy terminates.

The coverage provided with respect to any Dependent shall terminate on the earliest of the following dates:

1. The last day of the period through which the premium is paid;
2. The date the Policy terminates;
3. The date the Insured Student’s coverage terminates;
4. The date such Person is no longer a Dependent.

Definitions

"Covered Person"

means any eligible person or dependent that applies for coverage and for whom the required premium is paid.

“Injury”

means accidental bodily harm sustained by a Covered Person that results directly and independently from all other causes from a Covered Accident. The Injury must be caused solely through violent and accidental means. All Injuries sustained by one person in any one Accident, including all related conditions and recurrent symptoms of these Injuries, are considered a single Injury.

"Medically Necessary"

means a Treatment, service or supply that is: 1) required to treat an Injury or Sickness; prescribed or ordered by a Doctor or furnished by a Hospital; 2) performed in the least costly setting required by the Covered Person’s condition; and 3) consistent with the medical and surgical practices prevailing in the area for Treatment of the condition at the time rendered. Purchasing or renting 1) air conditioners; 2) air purifiers; 3) motorized transportation equipment; 4) escalators or elevators in private homes; 5) eye glass frames or lenses; 6) hearing aids; 7) swimming pools or supplies for them; and 8) general exercise equipment are not Medically Necessary. A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or Treatment alternative could have been used. We may consider the cost of the alternative to be the Covered Expense.

"Doctor"

means a licensed health care provider including a clinical social worker, a duly licensed and certified nurse practitioner, a physician's assistant, a dentist, and an optometrist acting within the scope of his or her license and rendering care or treatment to a Covered Person that is appropriate for the conditions and locality. It will not include a Covered Person or a member of the Covered Person's Immediate Family or household.

"Domestic Partner"

means an individual joined in a Domestic Partnership. "Domestic Partnership" means a civil contract entered into in person between two individuals of the same sex who are at least 18 years of age, who are otherwise capable and at least one of whom is a resident of Oregon.

"Sickness"

means an illness, disease or condition that causes a loss for which a Covered Person incurs medical expenses while covered under this Policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one Sickness.

"Usual and Customary Charge"

means not less than 80% of the prevailing amount charged by most providers for Treatment, service or supplies in the geographic area where the Treatment, service or supply is provided

Extension of Benefit

Benefits will extended up to 3 months, if a Covered Person’s coverage would otherwise end because the Insured is no longer enrolled as a full-time student if: 1) on the date insurance Covered Person has incurred expenses and is under a Doctor’s care for an Injury or Sickness covered by the Policy; or 2) the Covered Person is totally disabled due to an Injury or Sickness covered by the Policy. This would apply only if the required premium is paid. Benefits will not exceed the maximums shown in the Schedule of Benefits.

Pharmacy SmartCard

$36.00 for entire family , for one full year!

Enroll today and receive savings of 10% - 70% on prescription drugs available at local pharmacies! Anyone, at any age, may enroll! SmartCard services are provided through NPS.

The SmartCard is not an insurance product and is not underwritten by ACE American Insurance Company.

For more information on NPS, log on to www.pti-nps.com or call (800) 546-5677.

An ID card will be sent separately by NPS after your payment has been processed.

In order to receive discounts, you must present your ID card to the pharmacy each time you need a prescription for you or your family.

Filing A Claim

When covered expenses are incurred, the Covered Person must:

1. Fully complete both front and back pages of the claim form.
2. Obtain Doctor information and signature.
3. Attach all itemized bills.
4. Mail to the address on the claim form.

Claim forms must be filed within 90 days after the date of the Covered Injury or first Treatment for the Covered Sickness, or as soon as reasonably possible.

The Plan is Serviced by:

Bruce Ricks & Associates | PO Box 575 Sunnyside, WA 98944 | (800) 257-4257

The Plan is Administered by:

Myers-Stevens & Toohey & Co., Inc. | 26101 Marguerite Parkway Mission Viejo, CA 92692-3203 | (949) 348-0656 or (800) 827-4695 FAX (949) 348-2630 CA License #0425842

The Plan is Underwritten by:

ACE American Insurance Company | 436 Walnut Street Philadelphia, PA 19106

The PCC Contact Is:

Pat Delplanche Safety & Risk Services