Today’s Lecture
U of I Student Injury and Sickness
Insurance Plan
Undergraduate Plan
Benefit Provisions
General Limitations
Reduction of Benefits
Examples
Hospital Expense Benefits
Room and Board
Not to exceed average semi-private room rate
$100 deductible applies here
Hospital Expenses
Operating room, drugs, x-rays, laboratory
tests, medical supplies while confined
Hospital Expense Benefits
Example
Hospitalized for 10 days for meningitis
Room and board $500/day (ave. semi-private)
Room and board
$5000
Drugs
$2500
Lab Tests
$5000
Medical Supplies
$2000
Total hospital expenses $14,500
Hospital Expense Benefits
Example
You pay $100 deductible
Of the remaining $14,400, they pay
$8000 (80% of the next $10,000) plus
$4400 (all of the amount over $10,100)
Amount payable by Student Health Plan:
$12,400
You pay $2,100 ($100 deductible plus 20%
of $10,000)
Durable Medical Equipment
Only covered for accidental injury:
Splints, casts, crutches and braces
Accidental injury must have occurred while
insured
Dental
Lower of:
80% of Usual and Customary or
80% of Actual Charge
Deductible applies (if student)
Covered only for:
• Injury to Sound, Natural Teeth
• The removal of bony impacted wisdom teeth
• TMJ (Temporo-Mandibular Joint) disorder
General Exclusions
and Limitations
Pages 14-15
2 Addiction, such as nicotine
addiction
6 Cosmetic procedures, except
cosmetic surgery required to
correct an injury...
7 Dental treatment except as
specifically provided in the
Schedule of Benefits
14 Injury caused by or resulting
from the use of alcohol,
illegal drugs or any drugs or
medicines not taken in the
recommended dosage ...
16 Injury sustained participating
in interscholastic or
professional sport, contest or
competition (including
traveling or practicing)
18 Participation in a riot or civil
disorder; commission of or
attempt to commit a felony
23 Routine physical exams ...
26 Suicide or attempted suicide
while sane or insane (including
drug overdose) or intentionally
self inflicted injury
Sports Injuries
Page 7
“This plan covers injuries incurred while
participating in intercollegiate, club and
intramural sports, limited to $75,000.”
Page 17 – Intercollegiate Sports Benefit
“Insured student athletes who are members
of and are participating in intercollegiate
sports sponsored by the Policyholder are
covered for sports injury.”
Example
While attempting to rob a bank, you (a student)
accidentally shoot yourself in the foot. The police
easily catch you as you are trying to hop away.
They take you to the emergency room on the way to
jail. You are billed $500 for the emergency room.
How much does the U of I Student Plan pay?
A) 0
B) 240
C) 280
D) 350
E) None of the above
Reduction of Benefits
Applies when covered person has other valid
coverage, specifically:
Hospital or Medical Insurance
Group Insurance
Auto Medical Payments
Employee Benefit Plan
Does not include third party liability coverage
Calculating the Reduction of
Benefits
Initial Benefit Payment
Benefit is reduced by 50%
Statement
“No more than 100% of the eligible
expenses are compensable between this
Plan’s benefits and the benefits of any Other
Valid Coverage…”
Calculating the Reduction of
Benefits
If the Initial Benefit Payment (under U of I
plan) plus other benefits are less than 100%
of eligible expenses, then an Additional
Benefit Payment will be made.
Additional Benefit Payment = the lower of:
Normal Benefit - Initial Benefit Payment or
100% of Eligible Expenses - (Initial Benefit
Payment + Other Valid Coverage)
Example
You incur $5200 in Outpatient Miscellaneous
Illness and Accident Expenses during the
year.
Eligible Expenses
$5200
Normal Benefit
4040
[(5200-150) x .8 = $4040]
Other group insurance pays $2700.
Example - (Cont.)
Initial Benefit Payment
.5 x $4040
=
Other Valid Coverage =
Total
Additional Benefit Payable
Lower of
4040 - 2020
=
5200 - 4720
=
2020
2700
4720
2020
480
Example - (Cont.)
Total Benefit Payable
Initial Benefit Payment
Additional Benefit Payment
2020
480
2500
Insured receives $2500 from U of I Plan plus
$2700 from the other coverage for a total of
$5200, the total expenses.
Subrogation
This policy has the right to recover any benefits
paid if a third party is liable for the sickness or
injury. (Page 18)
Example
Plan pays $25,000 to a student injured in an
automobile accident. The total medical bills
were $30,000. If the student can collect a bodily
injury award of $75,000 from the driver of the
vehicle that covers all the medical bills plus pain
and suffering, the plan is entitled to recover the
$25,000 that it paid.
0
2007-08
2006-07
2005-06
2004-05
2002-03
2001-02
2000-01
1999-00
1998-99
1997-98
1996-97
1993-94
1990-91
1987-88
Insurance Premiums by Year
Undergraduate Plan
800
700
600
500
400
300
200
Student
Spouse
Child
100
180
160
140
120
100
80
60
40
20
0
2007-08
2006-07
2005-06
2004-05
2002-03
2001-02
2000-01
1999-00
1998-99
1997-98
1996-97
1993-94
1990-91
1987-88
Insurance Premiums by Year
Undergraduate Plan
Student