University of Texas PAN American International Student Insurance

	Study USA HealthCare Study USA Insurance meets all the requirements of the University of Texas PAN American. Students studying outside their home country Medical insurance which meets or exceeds the requirements set by the Department of State, Immigration & Naturalization Services and NAFSA. Widely accepted by U.S. universities.
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University of Texas PAN American International Student Insurance - Monthly Premium rates

Optional Additional Emergency Medical Evacuation

University of Texas PAN American International Student Insurance - Benefits

University of Texas PAN American International Student Insurance - Essential Information

• Eligibility of Coverage

• Period of Insurance

• Continuously Insured

• Preferred Provider Network

University of Texas PAN American International Student Insurance - Included Benefits

• Medical Expense

• Emergency Medical Evacuation

• Accidental Death & Dismemberment (AD&D)

• Mental or Nervous Disorders and Alcohol and Substance Abuse

• Repatriation of Remains

• Emergency Travelers Assistance Service

University of Texas PAN American International Student Insurance - Policy Exclusions

University of Texas PAN American International Student Insurance - Eligibility of Coverage

The following are eligible to enroll in the Study USA-HealthCare Insurance plan:

• Foreign Students Studying in the U.S. - Individuals under age 55 who have valid visa status in the U.S. and are registered and engaged in academic activities at a U.S. school, college or university;
• U.S. Registered Students Studying Outside the U.S. - Indviduals under age 55 who are registered with a U.S. school, college or university and engaged in academic activities abroad (excluding home country);
• Dependents - Spouse and/or children (under age 18) of enrolled students may apply for insurance with the student, or within 31 days of birth, legal adoption, marriage, or arrival in the country of study.

University of Texas PAN American International Student Insurance - Period of Insurance

1. Effective Date of Insurance. Provided the Enrollment Form is submitted and accepted and the required premium is paid, your insurance will become effective at 12:01 a.m. Standard Time on the latest of:
   • the Master Policy Effective Date;
   • the date you indicated on the Enrollment Form; or
   • the date the completed Enrollment Form and premium are received by the Program Administrator.
2. The Program is renewable up to a total of 48 months.
3. Termination of Insurance. Your insurance will terminate at 11:59 p.m. Standard Time on the earliest of:
   • the last day for which your premium has been paid;
   • the date you cease to be eligible for this insurance; or
   • the date the Master Policy terminates.
4. Termination of Insurance for Dependents. Your Dependent insurance will terminate on the earliest of:
   • the last day for which premium for the Dependent has been paid;
   • the date the Dependent ceases to be a qualified Dependent; or
   • the date your insurance terminates.

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University of Texas PAN American International Student Insurance - Continuously Insured

Any Covered Person who has continuous coverage under this Program from one year to the next shall be covered for conditions first Manifesting themselves while continuously insured. The total amount of benefits payable for an Injury or Illness cannot exceed the Aggregate Maximum per Injury or Illness under this Program.

During this Program year, a Covered Person must pay the appropriate premium and submit a completed Renewal Form within 30 days following the end of their current coverage period to avoid a lapse in coverage.

This continuously Insured provision will not establish a new benefit period, nor affect any lifetime or other maximum benefits shown for an incurred loss existing during any preceding coverage period.

University of Texas PAN American International Student Insurance - Preferred Provider Network

Utilizing the MultiPlan, Inc. Nationwide Preferred Provider Network will decrease a Covered Person’s out of pocket costs under this Program. Covered Persons may choose to be treated Inside or Outside the MultiPlan Network.

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University of Texas PAN American International Student Insurance - Medical Expense - A: $200,000 per incident / B: $250,000 per incident

If as the result of an Injury or Illness, a Covered Person incurs medical expenses, we will pay the covered percentage of the Covered Medical Expense incurred as described below and subject to the limitations, within 52 weeks from the date of the Injury or Illness or commencement of the first expense up to an Aggregate Maximum of Plan A - $200,000, Plan B - $250,000 per Injury or Illness. A Covered Person must receive treatment for an Injury or Illness within 30 days of the date of the Injury or Illness. The maximum amount payable due to a Pre-Existing Condition is $10,000.

Medical Benefit Schedule	In the MultiPlan Network or Outside the U.S.	Out of the MultiPlan Network
	After a $50 Deductible* / incident	After a $150 Deductible* / incident
Up to $25,000	The Program Pays Covered Medical Expenses: 80%
Plan A $25,000.01 - $200,000 Plan B $25,000.01 - $250,000	The Program Pays Covered Medical Expenses: In Network or outside U.S.: 100%, Out of Network: 80%
Out-Patient Doctor Visit Copay **	Insured Pays: $10
Emergency Room Visit Copay ** For Outpatient Only	Insured Pays: $50

*The deductible will be waived if medical service is first received from the Student Health Center. Otherwise, the Covered Person must pay the deductible. The Deductible shall not exceed $250 per Covered Person per Program year.

** The copay is in addition to the deductible above.

Benefits will be paid in Network level if: 1) treated by a provider who is a member of the MultiPlan Preferred Provider Network; 2) treated for a Medical Emergency; or 3) treated by a non MultiPlan provider when there is no MultiPlan provider qualified to provide the care needed within a 50 mile radius of the Covered Person's student residence.

University of Texas PAN American International Student Insurance - Covered Expenses

1. Charges made by a hospital for room and board, floor nursing and other services, inclusive of charges for professional services and with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the hospital’s average charge for semiprivate room and board accommodation.
2. Charges made for diagnosis, treatment and surgery by a physician.
3. Charges made for the cost and administration of anesthetics.
4. Charges for medication, x-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood transfusions, iron lungs, and medical treatment.
5. Charges for physiotherapy, if recommended by a physician for the treatment of a specific disablement and administered by a licensed physiotherapist.
6. Dressings, drugs and medicines that can only be obtained upon a written prescription of a physician or surgeon.
7. Dental Treatment: The Program will pay for treatment of Injury to sound natural teeth as any other injury up to $250.00 per tooth to a maximum of $1,000 per Injury.
8. Therapeutic Termination of Pregnancy: The Program will pay on the same basis as any other Illness up to a $500.00 maximum.
9. Chiropractic expenses: When it is medically necessary, the Program will pay up to a maximum of $35.00 per visit up to a maximum of 3 visits per week, for a maximum benefit of $1,000 per year.

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University of Texas PAN American International Student Insurance - Emergency Medical Evacuation Expense - A: $30,000/B: $30,000

If Injury or Illness commencing during the Period of Coverage requires emergency evacuation to either the nearest medical facility where appropriate medical treatment can be obtained, or to the Country of Residence, all expenses incurred are covered up to a limit of $30,000. An emergency evacuation must be recommended by a legally licensed physician who certifies that the severity of Injury or Illness necessitates such emergency evacuation and agreed to by you or your representative. Arrangements must be made by AIGAssist.

University of Texas PAN American International Student Insurance - Accidental Death & Dismemberment (AD&D) - A: $10,000/B: $10,000

If a Covered Person suffers an Injury which results directly in any of the losses shown in the Table of Losses below, such Covered Person will be entitled to the benefits shown if: a) the accidental bodily injury or injuries sustained by the Covered Person is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while coverage is in force and not while the Covered Person is in his Home Country; and b) the loss was suffered within 365 days of the accident.

For Loss of:	Benefit Amount
Life	$10,000
Both Hands, Both Feet or Sight of Both Eyes	$10,000
Either One Hand or One Foot and Sight of One Eye	$10,000
One Hand and One Foot	$10,000
Either Hand or Foot	$5,000
Sight of One Eye	$5,000

Loss means:

This benefit does not cover:

1. Any loss, fatal or non-fatal, caused by or resulting from: a) Intentionally self-inflicted injury, suicide while sane or attempted suicide while insane; b) War or any act of war, declared or undeclared, or service in the military, naval or air service of any country; c) Piloting or acting as a crew member, or riding in any aircraft except as a fare paying passenger on a scheduled airline; or d) The insured being under the influence of drugs (unless taken under the advice of a physician and within the amounts prescribed by a physician) or intoxicants of any type including Alcohol.
2. Any loss, fatal or non-fatal, caused by or resulting from: a) Illness, disease, pregnancy, childbirth, miscarriage; or any bacterial infection other than one occurring from an accidental cut or wound; or b) Hernia.

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University of Texas PAN American International Student Insurance - Mental or Nervous Disorders and Alcohol and Substance Abuse Benefits - A: $5,000/B: $5,000

This Program includes treatment for Mental or Nervous Disorders and Alcohol and Substance Abuse as follows:

When confined as an inpatient or when treated on an outpatient basis, the Program will pay the lesser of: a) The Usual, Reasonable and Customary Charge incurred for the first 30 days of hospital confinement per Program year; or b) 90% of the Usual, Reasonable and Customary Charge incurred up to a limit of $5,000.

University of Texas PAN American International Student Insurance - Repatriation of Remains Expense - A: $10,000/B: $10,000

If injury or Illness commencing during the Period of Coverage results in death, all reasonable expenses incurred for preparation and return of the remains to the Country of Residence will be paid up to a limit of $10,000. Arrangements must be made by AIGAssist.

University of Texas PAN American International Student Insurance - Emergency Travelers Assistance

STUDY USA-HEALTHCARE™ includes special services provided by AIGAssist, located in Houston, TX. You are eligible to use any of the assistance services below during the Period of Coverage. To arrange a medical evacuation or repatriation of remains, contact AIGAssist at 800-626-2427. If outside the U.S. and Canada, call collect 713-267-2525.

• 24-hour verification of medical coverage for hospitals and physicians.
• 24-hour medical care location service.
• Medical case monitoring, arranging communication between patient, family, physicians, employer, consulate or embassy.
• Emergency medical transportation arrangements.
• Emergency message service for medical situations.
• Multilingual services.
• 24-hour contact for legal emergencies.
• Legal referral, to help you locate a consular official or attorney.

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University of Texas PAN American International Student Insurance - Exclusions

This program does not cover loss caused by or resulting from, nor is any premium charged for, the following expenses:

1. Pre-Existing Conditions. A Pre-Existing Condition is defined as any injury or illness or condition which was contracted or which first manifested itself, or for which a licensed physician was consulted, or for which treatment or medication was prescribed, within 12 months prior to the effective date of the Covered Person's coverage under this Program. Pre-existing Conditions shall be excluded from coverage for a period of 12 months following the effective date of coverage under this program, unless stipulated by State or Federal Regulation. A Covered Person must be continuously insured. The maximum amount payable for a Pre-Existing Condition is $10,000;
2. Expenses in excess of Usual, Reasonable and Customary Charges;
3. Services normally provided without charge by the College’s health service, infirmary, or Hospital, or by health care providers employed by the College; or for any expenses for services rendered elsewhere which are available at the Student Health Service, infirmary, or hospital except in cases of Medical Emergency;
4. Eyeglasses, contact lenses, hearing aids, or prescriptions, examinations thereof, radical keratotomy or laser eye surgery to correct vision impairment;
5. Injury due to participation in a riot;
6. Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare paying passenger in an aircraft, operated by a scheduled airline maintaining regular published schedules on a regularly established route;
7. Injury sustained or Illness contracted while in the service of the Armed Forces of any country;
8. Treatment of mental or nervous disorders, except as specifically provided;
9. Elective treatment or elective surgery, except as specifically provided;
10. Treatment provided in a government Hospital unless there is a legal obligation to pay such charges in the absence of insurance;
11. Expenses incurred after the date of insurance termination for a Covered Person;
12. Congenital conditions, except as specifically provided for newborn infants;
13. Expenses incurred for services or supplies which are experimental or investigative in nature; including the treatment, procedure, facility, equipment, drugs usage, device or supplies;
14. Professional services rendered by a member of the Covered Person’s family or anyone who lives with the Covered Person;
15. Expenses incurred for services and supplies not: a) medically necessary for the diagnosis or treatment of any Injury or Illness; and b) recommended by the attending Physician;
16. Routine physicals other than Hospital nursery expense of a newborn baby;
17. Dental care, except as the result of injury to natural teeth caused by accident, any treatment identified as Temporomandibular Joint Dysfunction (TMJ);
18. Expenses incurred in connection with weak, strained or flat feet, corns, calluses, bunions, or toenails;
19. Expenses incurred for plastic or cosmetic surgery unless they result directly from an injury that necessitated medical treatment within 24 hours of the accident;
20. Expenses incurred as a result of diagnostic or surgical procedures in connection with infertility unless caused by an Injury or Illness;
21. Expenses incurred in connection with birth control, sterilization, or sterilization reversal, including surgical procedures and devices;
22. Expenses covered under any occupational benefit Policy, Workers’ Compensation Act or similar law, automobile medical payments or No-fault plans, public assistance programs, government plan or any other valid and collectible insurance;
23. War or any act of war, whether declared or undeclared;
24. Committing or attempting to commit an assault or felony, fighting or brawling, except in self-defense;
25. Suicide or intentionally self-inflicted injury while sane or insane;
26. Claims arising out of participation in interscholastic, intercollegiate or professional sporting events; racing; speed contests; skin diving; sky-diving; mountaineering (where ropes or guides are customarily used), para-sailing; hang gliding; bungee jumping; bob-sledding; travel on a snow mobile or ATV; any two or three wheeled motor vehicle; or private air travel, to include ballooning and ultra-light aircraft;
27. Expenses incurred while the Covered Person is intoxicated or under the influence of any drug unless taken under the advice of a licensed Physician;
28. Expenses resulting from a motor vehicle accident if the Covered Person is not properly licensed to operate the motor vehicle within the jurisdiction in which the accident takes place (this exclusion will not apply to passengers if they are insured under this Program);
29. Expenses for circumcision; tubal ligation; vasectomy; breast reduction; breast implants; sexual reassignment surgery; orthognathic surgery, including mandibular retrognathia; learning disabilities; smoking cessation; hair removal, replacement or hair growth; organ transplants;
30. Pregnancy or childbirth for a dependent child of an insured Student;
31. Expenses incurred in the Insured Person's country of permanent residence.

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