Section 5.8 University Risk Management: Student Intercollegiate Athletic Excess Accident Coverage
Issued: July 2013
Replaces: August 2012
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 establish a reserve fund for the Student Intercollegiate Athletic Excess Accident Plan. The Plan is established for the purpose of providing covered individuals, University student intercollegiate athletes, coverage up to established limits for medically necessary expenses resulting from a covered accident or a covered heart or circulatory malfunction accident , athletically related injuries, sustained while participating in a covered event, an intercollegiate sports activity, including covered team travel, competition, practices and conditioning sessions. The Plan is subject to a per-injury claim limit approved by the Vice President and shall be coordinated with the NCAA Athletic Catastrophe Coverage Program.
It is the responsibility of the Covered Individual to provide all pertinent information requested and to follow the University procedures.
Coverage is extended only when requested by the Intercollegiate Athletic Department prior to August 1 for annual coverage. The coverage shall be assessed and funded annually through the requesting Intercollegiate Athletic Department. This Program shall be effective at 12:00 a.m. on the first day of August, 2012, and shall remain in effect until such time as the Board of Trustees shall cancel the Plan.
No payment under this benefit shall be made for:
- Claims when notice was presented more than thirty (30) days after occurrence or commencement of a covered accident.
- Claims when the Covered Individual does not provide all pertinent information or does not follow the University procedures.
- Injuries or illnesses which are not a direct result of intercollegiate athletics participation during the date of the primary competitive season and designated off-seasons as approved by the Director of Athletics according to NCAA regulations.
- Injuries or illnesses which are a result of intramural, club sport, or recreational activities, training or conditioning activities that occur outside of the primary competitive season and designated off-season periods.
- Services rendered by physician or other medical provider without initiation or authorization by a member of the Sports Medicine Staff.
- Services or charges for which the Covered Individual is not legally obligated to pay.
- Treatment, services or supplies not Medically Necessary, or in excess of the Reasonable and Customary amount.
- Experimental or research treatment that is considered as such by the U.S. Department of Health and Human Services or any of its agencies.
- Cosmetic surgery or procedures unless actual damage resulted directly from a covered accident.
- Transportation costs other than for emergency ambulance services.
- Custodial, respite, rest or supportive care which does not assist the Covered Individual to recover from an Injury.
- Personal comfort items such as telephone, television or similar services.
- Charges for appliances prescribed for the purpose of preventing future injury.
- Services rendered by a University physician, nurse, trainer or any other person employed by the University.
- Injury which has its inception prior to the effective date of the coverage (any pre-existing condition).
- Expenses for athletic injuries incurred after completion of the student-athlete’s intercollegiate athletic eligibility.
- 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.
- Accident or injury covered by another insurance carrier, including but not limited to primary health or accident, general liability, auto liability, or motorcycle liability.
- 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.
- Injury or illness suffered by a Covered Individual where the University required the Covered Person to sign a waiver relieving the University of responsibility or liability based on notification by a Doctor that the Covered Individual’s participation exposed the Covered individual to increased risk for that type of injury, cardiovascular accident or stroke or other similar traumatic event incurred.
- Injury caused by or resulting from engaging in any act or occupation which is in violation of the law of the jurisdiction where the loss or cause of loss occurred. A violation of law includes both misdemeanor and felony violations.
- Injury that occurs while a Covered Individual has been determined to be intoxicated by judicial or administrative judgment or order; by evidence of an alcohol concentration in the Covered Individual’s blood, breath, or urine which equals or exceeds the limits set by applicable motor vehicle laws; or by other evidence demonstrating the insured was under the influence of any alcohol, narcotic, barbiturate or hallucinatory drug, unless the same was administered on the advice of a Physician and was taken according to the prescribed dosage.
- Injury caused by participation in a riot, rebellion or insurrection of any act or incident to any of these. For purposes of this exclusion, “participation” means to take an active part in common with others; “riot” means any use of or the threat to use force or violence by three or more persons without the authority of law.
- Disease, sickness bodily or mental infirmity and medical or surgical treatment for ptomaine or bacterial infection, other than bacterial infection occurring in consequence of a covered accidental cut or wound.
- Injury caused by exposure of the elements by or disappearance of a Covered Individual.
- Injury that occurs during travel to or from University supervised and sponsored play or practice of an eligible Sport that is not “Covered Travel”.
- With regard to aircraft, injury caused by boarding, alighting from, being struck by, or being on any aircraft owned, operated, or leased by the University, the Covered Individual or a member of the Covered Individual’s immediate family; flying in any aircraft which is rocket propelled; flying in any aircraft being used for aerobatics, racing or an endurance test, crop dusting, seeding, fertilizing or spraying, fighting a fire, any exploration, pipe or power line patrol, the pursuit of animals or birds, aerial photography, banner towing or skywriting, or any test or experimental purpose; flying when a special permit or waiver from the proper authority has to be issued; riding as a pilot, operator or “crew member” in any aircraft. “Crew member” means any person who has any duties aboard the aircraft.
- Cumulative Trauma/Cumulative Injury.
- War or act of war, whether declared or not.
- Terrorism or any act thereof.
C. Medical and Hospital Expense
The University will pay the actual reasonable and medically necessary expenses incurred within twenty-four (24) months from the date of occurrence of a covered accident for personal services of a legally qualified medical provider, hospital, physical therapy expenses, x-rays, prescription medication, rental of braces, crutches or wheelchairs, and transportation by emergency vehicle from the covered accident site to a hospital qualified to provide such treatment, when initiated or authorized by the University’s Sports Medicine Staff, not to exceed the limits hereinbefore specified.
D. 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.
"Athletically Related Injury” means injuries that are a direct result of participation in a covered event.
“Covered Accident" means an accident that occurs while the coverage is in effect, which directly results in bodily injury (not excluded from coverage by the Exclusions and Limitations) of a Covered Individual, and which: a) occurs while he or she is participating in a Covered Event; or b) occurs during Covered Travel to or from the location of a Covered Event; or c) occurs during a temporary stay at the location of a Covered Event held away from the University while the Covered Individual is engaged in an activity or travel that is authorized by, organized by or directly supervised by an official representative of the University.
“Covered Event” means any University authorized, organized or directly supervised Qualifying Intercollegiate Sport activity, including team travel, competition, practices and conditioning sessions during the playing season.
“Covered Travel” means team or individual travel, for purposes of representing the University, that is to or from the location of a Covered Event and is authorized by the University, provided the travel is paid for or subject to reimbursement by the University. Covered Travel to a Covered Event will commence upon embarkation from an authorized departure point and terminate upon arrival at the location of the Covered Event. Covered Travel from a Covered Event will commence upon departing from the location of the covered Event and terminate upon return to the authorized place from which such Covered Travel to the Covered Event began.
“Hospital” means an institution, which meets all of the following requirements: a) it is licensed (if required by law) as a hospital by applicable licensing authorities; b) it is open at all times; c) it is operated mainly to diagnose and treat illnesses on an inpatient basis; d) it has a staff of one (1) or more Doctors on call at all times; e) it has twenty-four (24) hour nursing services by Registered Nurses; and f) it is not mainly a skilled nursing facility, clinic, nursing home, rest home, convalescence home, or like place; and g) it has organized facilities for major surgery or provides for such facilities for its patients through formal written agreement with other Hospitals.
“Immediate Family” means the mother, father, sister, brother, husband, wife, or children of the Covered Individual, any other members of the same household as the Covered Individual, or any other person legally responsible for the care of the Covered Individual.
“Incur” or “Incurred” means that an expense is sustained by the Covered Individual, after all adjustments (including, but not limited to, discounts, write-offs and negotiated fees). A Covered Loss shall be considered to be Incurred on the date the treatment or service is rendered or the purchase or rental occurs.
“Covered Individual” means: a) a student-athlete including student cheerleaders, dance team members, and mascots, participating in a covered event in an intercollegiate sport as recognized by the University; and b) a prospective student-athlete participating in a covered event who has graduated from high school and signed a National Letter of Intent or a written officer of admission or financial aid to participate in an intercollegiate sport at the University.
“Medically Necessary” means a service or supply that is ordered, prescribed or rendered by a Doctor or hospital and determined by the University to be: a) provided for the diagnosis or treatment of the patient’s condition; b) appropriate and consistent with the symptoms and findings or diagnosis and treatment of the Covered Individual’s condition; c) provided in accordance with generally accepted professional standards or medical practice; d) the most appropriate supply or level of service which can be provided on a cost effective basis (including but not limited to inpatient vs. outpatient care, electric vs. manual wheelchair, surgical vs. medical or other types of care). The fact that a Doctor may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service or supply Medically Necessary.
“Qualifying Intercollegiate Sport” means a sport: a) which has been accorded varsity status by the University as an NCAA sport; b) which is administered by a University department of Intercollegiate Athletics; c) for which the eligibility of the participating Student athlete is reviewed and certified in accordance with NCAA legislation, rules, or regulations; and d) which entitles qualified participants to receive the University official awards.
“Student” means an individual who is actually enrolled and attending school as a full time Student at the University.
“Covered Heart or Circulatory Malfunction Accident” means a cardiovascular accident, stroke or other similar traumatic event, which is independent of disease, illness, or other cause, occurring which within 24 hours of participating in a Covered Activity supported by satisfactory evident that participation in the Covered Activity precipitated the medical necessity of treatment. However, no further treatment will be covered if the symptoms are diagnosed as disease, illness or other no-accidental cause.
F. Subrogation Clause
The Board of Trustees of Southern Illinois University shall be subrogated to all rights of recovery which a person covered under this Plan may have, to the extent payment is made under this Plan for, or on behalf of, such person. Such person agrees to render reasonable assistance to the University to secure such rights, and such person shall do nothing after a loss to prejudice such rights. Prejudicing said subrogation rights may result in loss of coverage under the Plan or personal liability to the University.
G. 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 requesting department, deposited into the Self-Insurance Student Intercollegiate Athletic Excess Accident account and, after appropriate processing, payment of all valid claims and/or indemnities from the account shall be made.
- Annual contributions shall be assessed with coverage terms extended from 12:00 a.m. August 1 to 11:59 p.m. July 31.
- 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. Notice given after (30) days after the accident 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 to the Sports Medicine Staff.
- 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.