Section 5.6 University Risk Management: Excess Medical Benefits
Issued: July 2013
Replaces: July 2010
The coverage described herein is provided as part of the Southern Illinois University Self-Insurance Program, and anything herein conflicting with the Program is hereby amended to comply with said Program.
The Board of Trustees of Southern Illinois University does hereby provide to non-University personnel (as defined below), participating in sponsored camps, child care, or other approved programs or activities, excess medical benefits as specified below.
Excess Medical Benefit Coverage is a non-liability, limited scope, expected, excess medical benefit extended by the University.
Coverage is extended only when requested by the sponsoring department prior to the beginning date of camp, program, or July 1 for annual coverage. Under no circumstances will coverage be retroactive.
This benefit became effective on the 1st day of January, 1987, and shall remain in effect until such time as the Board of Trustees shall cancel the Program. Effective July 1, 2010, this benefit became effective for child care and other approved programs or activities. Effective July 1, 2013, this benefit became excess of other available insurance. "Non-University personnel" shall be defined for the purposes of this Program as all persons participating in University-sponsored camp activities, child care programs, or other approved programs or activities who are not faculty members, staff, or students eligible for student medical benefits, and shall be referred to herein as "Participant." Temporary extra-help camp counselors shall be eligible for coverage.
This benefit, subject to exclusions, covers, up to established limits, against loss resulting directly and indirectly from all causes of accidental bodily injury, which is sustained during the term of this benefit, hereinafter referred to as "such injury," and loss resulting from sickness which is contracted during the term of this benefit, hereinafter referred to as "such sickness," and is sustained:
- While in or on buildings or premises of the University during the time the Participant is required to be therein or thereon by reason of attendance at the University on any regular camp or activity day; or
- While in attendance at or participating in a regularly scheduled camp or program activity approved by proper authority of the University; or
- While traveling directly to or from such regularly scheduled and approved camp or program activity with other Participants of the University as a group, provided such group is at the time under supervision of proper University authority.
No payment under this benefit shall be made for:
- Claims presented more than thirty (30) days after occurrence/ commencement of a covered accident or illness.
- Services rendered by a camp physician, camp nurse, or any other person employed by the camp.
- Services rendered by any counselor, group leader, chaperon, or any other person accompanying the Participant to the camp.
- Injury or sickness which has its inception prior to the effective date of the coverage (any pre-existing condition).
- Eyeglasses, examinations or prescriptions therefore, unless actual damage to the eye shall result from a covered accident.
- Dental treatment, dental x-rays, crowns, fillings, dentures or replacement of dental work, unless damage to sound, natural teeth shall result from a covered accident.
- Mental or nervous disorders.
- Disability or injury covered under any Worker's Compensation law or other employee benefit while working full or part-time in the camp of the University.
- Drugs or medications unless prescribed by a physician as a result of a covered accident or sickness.
- Suicide, attempted suicide, self-inflicted injury, or injury resulting from the illegal or improper use of controlled substances.
- Accident or injury covered by another insurance carrier, including but not limited to primary health or accident, general liability, auto liability, or motorcycle liability.
C. Accidental Death and Dismemberment Benefit
If injury shall result in any of the covered losses within 180 days following the date of accident, the University shall pay an amount specified, but only the greatest of such specified amounts shall be paid for every one accident with respect to any one Participant irrespective of the number of injuries which may be applicable for the loss of life; both hands or both feet; entire sight of both eyes; entire sight of one eye; one hand and one foot; one hand and the sight of one eye; or one hand or one foot.
"Loss" as used above shall mean, with reference to hand or foot, actual severance through or above the wrist or ankle joint. Loss of sight of an eye shall mean the entire and irrecoverable loss of sight thereof.
Indemnity for loss of life shall be payable to the Estate of the Participant. All other indemnities under this Program shall be paid to the Participant only as a reimbursement for expenses incurred as a direct result of a covered loss. If any indemnity under this Program shall be payable to a minor or other not competent to give a valid release, the University will pay such indemnity, up to the Principal Sum, to any individual who offers affirmative proof that he/she is equitably or legally entitled thereto. Any payment made by the University in good faith pursuant to this provision shall fully discharge the University to the extent of such payment.
D. Medical and Hospital Expense
The University will pay the actual reasonable and necessary expenses excess of other available insurance incurred within fifty-two (52) weeks from the date of occurrence of a covered accident or from the date of commencement of a covered sickness for the personal services of a legally qualified medical provider, hospital confinement, the employment of a licensed nurse, physical therapy expenses, x-rays, prescription medication, rental of braces, crutches or wheelchairs, and transportation by emergency vehicle from the camp to the Participant's residence or to a hospital qualified to provide such treatment, not to exceed the limits hereinbefore specified and determined annually by the Director and approved by the Senior Vice President.
E. Other Insurance
The Plan is excess to any other health insurance, benefit plan or insurance coverage from which the student may be entitled. This Plan will not pay primary or other insurers discounts and or usual and customary write offs.
F. Contribution Rates
- Contribution rates shall be determined annually by the Director based on loss experience and shall be approved by the Senior Vice President.
- Contributions shall be collected from the sponsoring department on an annual or per day basis.
- Annual contributions shall be assessed with coverage terms extended from 12:00 a.m. July 1 to 11:59 p.m. June 30.
- A benefit limit shall be determined on an annual basis.
- The notice of claim must be submitted to University Risk Management with thirty (30) days of the covered accident or injury. Notice given after (30) days will not be paid.
- Covered Individuals must submit all medical expenses to primary and other available insurance and must provide Explanation of Benefits (EOB) and copies of detailed medical bills in a timely manner.
- Incurred claims expense will be considered after all adjustments (including, but not limited to, discounts, write-offs and negotiated fees) and shall be paid directly to the provider.
- The program will not pay more than the annually determined benefit limit on an accident or participant basis.