Texas
Accident Only
CERTIFICATE OF INSURANCE
for
St. Mary’s University
Underwritten by Tufts Insurance Company
Administered by Christie Student Health Plans, LLC
This is an Accident Only Certificate. It does not pay for benefits for loss from
sickness. This is an Excess Only Policy. It provides supplemental coverage
and is not intended to cover all medical expenses. See the “Excess Provision”
in Section 4.
THIS CERTIFICATE IS NOT A MEDICARE SUPPLEMENT CONTRACT.
If You are eligible for Medicare, review the “Guide to Health Insurance for People with
Medicare” available from Us.
TX-ACC-001 Ed. 1-2015
This Certificate shall be effective on the Effective Date and shall continue in force until
terminated as provided herein.
Policy Number:
SP100102-3
Date of Issue:
08/02/2016
Effective Date:
08/02/2016
Term of Policy:
08/02/2016-08/01/2017
This Certificate is governed by applicable federal law and the laws of Texas.
Signed at Tufts Insurance Company, Watertown, Massachusetts, on the date of issue:
Officer of Tufts Insurance Company
Countersigned at School Name,
,
Tufts Insurance Company
705 Mt. Auburn Street
Watertown, MA 02472
2
Italicized words are defined in Section 3
To contact Member Services, call 1-844-603-6192
Or see Our website at www.christiestudenthealth.com/stmarytx/
IMPORTANT NOTICE
AVISO IMPORTANTE
To obtain information or make a
complaint:
Para obtener informacion o para
someter una queja:
You may call Tufts Insurance Company’s
toll-free telephone number for information
or to make a complaint at:
Usted puede llamar al numero de telefono
gratis de Tufts Insurance Company’s para
informacion o para someter una queja al:
1-844-603-6192
You may contact the Texas Department of
Insurance to obtain information on
companies, coverages, rights or
complaints at:
1-800-252-3439
1-844-603-6192
Puede comunicarse con el Departamento
de Seguros de Texas para obtener
informacion acerca de companias,
coberturas, derechos o quejas al:
1-800-252-3439
You may write the Texas Department of
Insurance:
Puede escribir al Departamento de
Seguros de
Texas:
P.O. Box 149104
Austin, TX 78714-9104
Fax: (512) 475-1771
Web: www.tdi.texas.gov
E-mail:
[email protected]
P.O. Box 149104
Austin, TX 78714-9104
Fax: (512) 475-1771
Web: www.tdi.texas.gov
E-mail:
[email protected]
PREMIUM OR CLAIM DISPUTES: Should
you have a dispute concerning your
premium or about a claim you should
contact the company first. If the dispute is
not resolved, you may contact the Texas
Department of Insurance.
DISPUTAS SOBRE PRIMAS O
RECLAMOS: Si tiene una disputa
concerniente a su prima o a un reclamo,
debe comunicarse con el la compania
primero. Si no se resuelve la disputa,
puede entonces comunicarse con el
departamento (TDI).
ATTACH THIS NOTICE TO YOUR
POLICY: This notice is for information only
and does not become a part or condition of
the attached document.
UNA ESTE AVISO A SU POLIZA: Este
aviso es solo para proposito de
informacion y no se convierte en parte o
condicion del documento adjunto.
Italicized words are defined in Section 3
3
To contact Member Services, call 1-844-603-6192
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YOUR CERTIFICATE OF INSURANCE
THIS BOOKLET IS YOUR CERTIFICATE OF INSURANCE for benefits offered by Christie Student
Health Plans, LLC (“CSH”) and underwritten by Tufts Insurance Company (“TIC”). Certain services
have been delegated to others, including, but not limited to Cigna and its affiliates (collectively,
“Cigna”). CHS, TIC, Cigna and other delegated entities may be collectively referred to, throughout
this Certificate, as “We,” “Us,” or “Our,” and a Covered Person is sometimes referred to as “You” or
“Your.”
This Certificate describes the benefits, exclusions, conditions and limitations provided to Covered
Persons. It replaces any Certificate previously issued to You. You should read this Certificate for a
complete description of benefits.
Italicized words are defined in Section 3
4
To contact Member Services, call 1-844-603-6192
Or see Our website at www.christiestudenthealth.com/stmarytx/
IMPORTANT INFORMATION
Appeals and Grievances Department
If You need to call Us about a concern or appeal, contact Our Member Services Department at 1844-603-6192. To submit Your appeal or grievance in writing, send Your letter to:
Christie Student Health
Attn: Appeals and Grievances Department
80 Hayden Avenue
Lexington, MA 02421
In-Network and Out-of-Network Level of Benefits
If You need services covered under this Certificate, You may choose to obtain services from either
a Network Provider (In-Network Level of Benefits) or any Non-Network Provider (Out-of-Network
Level of Benefits):
In-Network Level of Benefits: If Your care is provided by a Network Provider and, in certain
instances, authorized by Us, You will be covered at the In-Network Level of Benefits.
Out-of-Network Level of Benefits: If Your care is provided by a Non-Network Provider or
provided by a Network Provider and not authorized by Us, You will be covered at the Out-ofNetwork Level of Benefits.
Member Services Department
You can reach Our Member Services Department at 844-603-6192 from 8:30 a.m. – 5:30 p.m.
Central Standard Time, Monday through Friday. Call Us with any questions You may have about
this Certificate.
Texas Department of Insurance
You may contact the Texas Department of Insurance to obtain information on companies,
coverages, rights or complaints at (800) 252-3439.
You may write the Texas Department of Insurance at:
P.O. Box 149104
Austin, TX 78714-9104
Fax: (512) 475-1771
Web: http://www.tdi.state.tx.us
E-mail: [email protected]
Notice of Material Modification
You will be provided a notice of any material modification in Covered Services under this Certificate
at least 60 days before the Effective Date of the modification. Any changes in clinical criteria will be
identified, if applicable, along with full details of the effect of these changes, if any, on Your
personal liability for the cost of such changes.
Services for Hearing Impaired
If You are hearing impaired, the following services are provided:
Italicized words are defined in Section 3
5
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Telecommunications Device for the Deaf (TDD)
If You have access to a TDD phone, call 844-603-6192 You will reach the Member Services
Department.
Texas Relay
1-800-735-2989
Website
For more information and to learn more about self-service options that may be available to You,
please go to www.christiestudenthealth.com/stmarytx/
Italicized words are defined in Section 3
6
To contact Member Services, call 1-844-603-6192
Or see Our website at www.christiestudenthealth.com/stmarytx/
TABLE OF CONTENTS
Schedule of Benefits
Section 1
Eligibility, Effective Date of Coverage
Section 2
Definitions
Section 3
Coverage
Section 4
Termination of Coverage
Section 5
General Provisions
Section 6
Exclusions and Limitations
Section 7
How to File a Claim and Member Satisfaction
Section 8
Italicized words are defined in Section 3
7
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SECTION 1 – SCHEDULE OF BENEFITS
Deductible amount per Covered Person per Accident per Contract Year:
$0
Maximum amount of Accident Medical Expense Benefits per Covered Person per Injury per
Contract Year: $5,000
ACCIDENT MEDICAL EXPENSE BENEFITS
Benefits Payable
After any applicable Deductible, the Accident Medical Expense Benefits payable under this
Certificate in a Contract Year are paid at the Covered Percentage. Please see the “Your Cost”
column for Your financial responsibilities.
YOUR COST
ACCIDENT MEDICAL EXPENSE
BENEFITS
Hospital Expenses
Covered Percentage
Maximum Number of Weeks per Injury
Surgical Expenses
Covered Percentage
Network Provider
Non-Network Provider*
20% Coinsurance
40% Coinsurance
52
52
20% Coinsurance
40% Coinsurance
Maximum Number of Weeks per Injury
Provider Services Expenses
Covered Percentage
52
52
20% Coinsurance
40% Coinsurance
Maximum Number of Weeks per Injury
52
52
Italicized words are defined in Section 3
8
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YOUR COST
Network Provider
Non-Network Provider*
20% Coinsurance
20% Coinsurance
52
52
20% Coinsurance
40% Coinsurance
52
52
20% Coinsurance
40% Coinsurance
52
52
20% Coinsurance
40% Coinsurance
52
52
20% Coinsurance
40% Coinsurance
Maximum Number of Weeks per Injury
52
52
Durable Medical Equipment
Expenses
Covered Percentage
Maximum Number of Weeks per Injury
20% Coinsurance
52
40% Coinsurance
52
ACCIDENT MEDICAL EXPENSE
BENEFITS
Ambulance Expenses
Covered Percentage
Maximum Number of Weeks per Injury
Laboratory and X-ray Outpatient
Expenses
Covered Percentage
Maximum Number of Weeks per Injury
Anesthesia Expenses
Covered Percentage
Maximum Number of Weeks per Injury
Blood Expenses – Transfusion or
Dialysis
Covered Percentage
Maximum Number of Weeks per Injury
Physical or Occupational Therapy
Expenses
Covered Percentage
Italicized words are defined in Section 3
9
To contact Member Services, call 1-844-603-6192
Or see Our website at www.christiestudenthealth.com/stmarytx/
YOUR COST
ACCIDENT MEDICAL EXPENSE
BENEFITS
Prosthetic & Orthotic Devices Expenses
Covered Percentage
Maximum Number of Weeks per Injury
Prescription Drug Expenses
Covered Percentage
Maximum Number of Weeks per Injury
Dental Injury Expenses
Covered Percentage
Maximum Number of Weeks per Injury
Home Health Care Expenses
Covered Percentage
Maximum Number of Weeks per Injury
Hospice Care Expenses
Covered Percentage
Italicized words are defined in Section 3
Network Provider
Non-Network Provider*
20% Coinsurance
40% Coinsurance
52
52
20% Coinsurance
40% Coinsurance
52
52
20% Coinsurance
20% Coinsurance
52
52
20% Coinsurance
40% Coinsurance
52
52
20% Coinsurance
40% Coinsurance
10
To contact Member Services, call 1-844-603-6192
Or see Our website at www.christiestudenthealth.com/stmarytx/
YOUR COST
Network Provider
Non-Network Provider*
52
52
20% Coinsurance
40% Coinsurance
Maximum Number of Weeks per Injury
52
52
Accidental Repetitive Motion Injury
Treatment Expenses
Covered Percentage
20% Coinsurance
40% Coinsurance
Maximum Number of Weeks per Injury
52
52
ACCIDENT MEDICAL EXPENSE
BENEFITS
Maximum Number of Weeks per Injury
Accidental Heart & Circulatory
Malfunction Treatment Expenses
Covered Percentage
* NOTE: If You receive health care services from a Non-Network Provider, You may be
responsible for any balance billing from the Non-Network Provider in addition to Your
Copayment or Coinsurance at the Out-of-Network Level of Benefits.
Italicized words are defined in Section 3
11
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Or see Our website at www.christiestudenthealth.com/stmarytx/
SECTION 2 – ELIGIBILITY, EFFECTIVE DATE OF COVERAGE
Eligibility
The following persons are eligible and considered Covered Persons under this Certificate:
Intercollegiate student athletes, intramural student athletes, club student athletes, student
trainers, team mascots, coaches and student managers are automatically enrolled in this
Certificate.
Effective Date of Insurance
Each eligible person under this Certificate on or before the Effective Date will be a Covered
Person on the Effective Date of this Certificate.
Italicized words are defined in Section 3
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SECTION 3 –DEFINITIONS
This section defines the terms used in this Certificate.
Accident (Accidental) is an occurrence which (a) is unforeseen, (b) is not due to or contributed
to by sickness or disease of any kind, and (c) causes Injury.
Accident Medical Expenses shall have the meaning set forth in Section 4 of this Certificate.
Adverse Benefit Determination means any of the following, in accordance with federal law (29
C.F.R. 2560.503-1): a denial, reduction, or termination of, or a failure to provide or make
payment (in whole or in part) for, a benefit including any such denial, reduction, termination, or
failure to provide or make payment that is based on a determination of a participant’s or
beneficiary’s eligibility to participate in a plan, and including, with respect to group health plans,
a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in
part) for, a benefit resulting from the application of any utilization review, as well as a failure to
cover an item or service for which benefits are otherwise provided because it is determined to
be Experimental or Investigative or not Medically Necessary or appropriate.
Brand Drug is a Prescription Drug which is protected by trademark registration.
Certificate means this document, and any future amendments, which describes the benefits
under the Master Policy.
Coinsurance is the Covered Person’s share of costs for certain Covered Services. For services
provided by a Non-Network Provider, the Covered Person’s share is a percentage of the
Reasonable Charge. For services provided by a Network Provider, to the extent that there is
Coinsurance, the Covered Person’s share is a percentage of: (1) the applicable network fee
schedule amount for those services and (2) the Network Provider’s actual charges for those
services, whichever is less. Note: The Covered Person’s share percentage is based on the
Network Provider payment at the time the claim is paid. It does not reflect any later
adjustments, payments, or rebates that are not calculated on an individual claim basis.
Contract Year is the period of time from anniversary date to anniversary date, except in the
first year when it is the period of time from the Effective Date to the first anniversary date.
Copayment is a Covered Person’s payment for certain Covered Services provided by either a
Network Provider or a Non-Network Provider. The Covered Person pays Copayment to the
Provider at the time services are rendered, unless the Provider arranges otherwise.
Covered Activity means a covered sport or school sponsored activity in which a Covered
Person may participate.
Covered Service(s) mean the treatment, services and supplies for which benefits are provided
under the Certificate. They must be:

described in Section 4 of this Certificate (they are subject to the "Exclusions from
Limitations" section in Section 7); and
Italicized words are defined in Section 3
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
Medically Necessary.
Note: Covered Services may not include any tax, surcharge, assessment or other similar fee
imposed under any state or federal law or regulation on any Provider, Covered Person,
service, supply or medication.
Covered Person(s) is any person defined as eligible under “Eligibility” in Section 2 of this
Certificate who participates as a member of the School’s Covered Activities.
Day Surgery is any surgical procedure(s) provided to a Covered Person at a facility licensed
by the state to perform surgery, and with an expected departure the same day, or in some
instances, within 24 hours.
Deductible means, for each Contract Year, the amount paid by the Covered Person for certain
Covered Services before any payments are made under this Certificate. Costs in excess of the
Reasonable Charge and Copayments do not count toward the Deductible.
Note: The amount credited towards the Covered Person’s Deductible is based on the
Network Provider’s negotiated rate at the time the services are rendered or Non-Network
Provider’s reasonable charge at the time services are rendered. It does not reflect any later
adjustments, payments, or rebates that are not calculated on an individual claim basis.
Dentist is a health care professional licensed in accordance with applicable state law who
specializes in the diagnosis, prevention, and treatment of diseases and conditions of the oral
cavity.
Durable Medical Equipment means devices or instruments of a durable nature that:







are reasonable and necessary to sustain a minimum threshold of independent daily
living;
are made primarily to serve a medical purpose;
are not useful in the absence of illness or Injury;
can withstand repeated use;
can be used in the home;
are not for use in altering air quality or temperature; and
are not for exercise or training.
Effective Date means the date, according to Our records, when You become a Covered
Person and are first eligible for Covered Services.
Emergency is a medical condition, whether physical, behavioral, related to substance abuse,
or mental, that manifests itself by symptoms of sufficient severity, including severe pain, that
the absence of prompt medical attention could reasonably be expected by a prudent
layperson, who possesses an average knowledge of health and medicine, to result in:

serious jeopardy to the physical and / or mental health of a Covered Person, or
Italicized words are defined in Section 3
14
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


serious impairment to bodily functions, or
serious dysfunction of any bodily organ or part, or
in the case of a pregnant woman, serious jeopardy to the health of the fetus.
Experimental or Investigative means a service, supply, treatment, procedure, device, or
medication (collectively “treatment”) if any of the following apply:





the drug or device cannot be lawfully marketed without the approval of the U.S. Food
and Drug Administration and approval for marketing has not been given at the time the
drug or device is furnished or to be furnished; or
the treatment, or the "informed consent" form used with the treatment, was reviewed
and approved by the treating facility's institutional review board or other body serving a
similar function, or federal law requires such review or approval; or
reliable evidence shows that the treatment is the subject of ongoing Phase I or Phase II
clinical trials; is the research, experimental, study or investigative arm of ongoing Phase
III clinical trials; or is otherwise under study to determine its safety, efficacy, toxicity,
maximum tolerated dose, or its efficacy as compared with a standard means of
treatment or diagnosis; or
evaluation by an independent health technology assessment organization has
determined that the treatment is not proven safe and/or effective in improving health
outcomes or that appropriate patient selection has not been determined; or
the peer-reviewed published literature regarding the treatment is predominantly nonrandomized, historically controlled, case controlled, or cohort studies; or there are few
or no well-designed randomized, controlled trials.
Note: We do not consider treatment for a Phase IV clinical trial to be Experimental or
Investigative, if that treatment is required by state or federal law.
Hospice is a facility or program providing a coordination program of home and inpatient care
which treats terminally ill patients. The program provides care to meet the special needs of the
patient during the final stages of a terminal illness. Care is provided by a team made up of
trained medical personnel, counselors, and volunteers. The team acts under an independent
hospice administration and it helps the patient cope with physical, psychological, spiritual,
social, and economic stresses. The hospice administration must meet the standards of the
National Hospice Organization and any licensing requirements.
Hospital is a facility which provides in-patient services for the care and treatment of injured and
sick people, provides Room and Board services and nursing services 24 hours a day, has
established facilities for diagnosis and major surgery, and is run as a Hospital under the laws
of the jurisdiction in which it is located.
Injury is a bodily injury caused by an Accident. This includes related condition and recurrent
symptoms of such injury.
In-Network Level of Benefits means the level of benefits that a Covered Person receives when
Covered Services are provided by a Network Provider.
Italicized words are defined in Section 3
15
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Inpatient means a patient who is (a) admitted to a Hospital or other facility licensed to provide
continuous care and (b) classified as a resident bed patient for all or a part of the day.
Intensive Care Unit is a designated ward, unit, or area within a Hospital for which a specified
extra daily surcharge is made and which is staffed and equipped to provide, on a continuous
basis, specialized or intensive care or services not regularly provided within such Hospital.
Master Policy means the agreement between the School and Us under which We agree to
provide group coverage and the School agrees to pay a premium to Us on Your behalf. The
Master Policy includes this Certificate and any amendments.
Medically Necessary or Medical Necessity means a service or supply that is:
 appropriate, in terms of type, amount, frequency, level, setting and duration to the
Covered Person’s diagnosis or condition; or
 informed by generally accepted medical or scientific evidence and consistent with
general accepted practice parameters.
In determining coverage for Medically Necessary Services, We use Medical Necessity
Guidelines. These Guidelines are:




developed with input from Network Providers;
developed in accordance with the standards adopted by national accreditation
organizations;
updated at least biennially or more often as new treatments, applications and
technologies are adopted as generally accepted professional medical practice; and
evidence-based, if practicable.
The fact that a physician or other health care provider may prescribe, authorize, or direct a
service does not of itself make it Medically Necessary or covered by this Certificate.
Network Hospital is a Hospital which has an agreement either with Us directly or with a
Provider network with whom We have a contract to provide certain Covered Services to
Covered Persons. Network Hospitals are independent and not owned by or agents or
representatives of Us, and their staffs are not Our employees. Network Hospitals are subject
to change.
Network Provider is a Provider who:


Has an agreement either with Us directly or with a Provider network with whom We
have a contract to provide Covered Services to Covered Persons.
Is not a Network Provider and provides Covered Services for an Emergency medical
condition when travel to a Network Provider prior to treatment is not feasible.
Non-Network Provider is a Provider who does not have an agreement either with Us directly or
with a Provider network with whom We have a contract to provide Covered Services to
Covered Persons.
Observation is the use of hospital services to treat and/or evaluate a condition that should
Italicized words are defined in Section 3
16
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result in either a discharge within twenty-three (23) hours or a verified diagnosis and
concurrent treatment plan. At times, an Observation stay may be followed by an Inpatient
admission to treat a diagnosis revealed during the period of Observation.
Orthodontic Treatment is any medical service or supply or dental service or supply that is
furnished to prevent or to diagnose or to correct a misalignment of the teeth, the bite, the jaws
or jaw joint relationship, whether or not for the purpose of relieving pain. The installation of a
space maintainer or surgical procedure to correct malocclusion is not included.
Out-of-Network Level of Benefits means the level of benefits that a Covered Person receives
when Covered Services are not provided by a Network Provider. See Section 1 for more
information.
Outpatient means a patient who receives care other than on an Inpatient basis. This includes
services provided in Provider’s office, a Day Surgery or ambulatory care unit, an Emergency
room or Outpatient clinic, and when You are in a facility for Observation.
Pharmacy is an establishment where prescription drugs are legally dispensed.
Primary Care Provider is a Provider who is a general practitioner, family practitioner, physician
assistant, nurse practitioner, internist, pediatrician, obstetrician/gynecologist, or a student
health center who provides primary care services.
Prescription Drug is any of the following:


A drug, biological, or compounded prescription which, by law, may be dispensed only by
prescription.
Injectable insulin, disposable needles and syringes, when prescribed and purchased at
the same time as insulin and disposable diabetic supplies.
Provider is a physician, other health care professional, health care facility, or Urgent Care
Center licensed or certified to provide medical services or supplies. We will only cover
services of a Provider, if those services are listed as Covered Services and within the scope of
the Provider’s license.
Reasonable Charge is the lesser of:


The amount charged by the Non-Network Provider; or
The amount that We determine to be reasonable. We decide this amount based on
nationally accepted means and amounts of claims payment. These means and amounts
include, but are not limited to: Medicare fee schedules and allowed amounts; CMS
medical coding policies; AMA CPT coding guidelines; nationally recognized academy
and society coding and clinical guidelines.
Room and Board is a charge made by a facility for housing, food and other necessary
services and supplies.
School means a school, college or university with which We have an agreement to provide
Italicized words are defined in Section 3
17
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School coverage. If You are covered under a Master Policy, the School is Your agent and is
not Our agent.
Specialist Provider is a physician specialist (other than the Covered Person’s PCP) is a
Provider who focuses on a specific area of medicine or a group of patients to diagnose,
manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist
is a Provider who has more training in a specific area of healthcare.
Stay means an inpatient confinement for which a Room and Board charge is made.
Surgery or Surgical Procedure means the diagnosis and treatment of Injury by manual and
instrumental means, such as cutting, abrading, suturing, destruction, ablation, removal,
lasering, introduction of a catheter (e.g., heart or bladder catheterization) or scope (e.g.,
colonoscopy or other types of endoscopy), correction of fracture, reduction of dislocation,
application of plaster casts, injection into a joint, injection of solution or otherwise physically
changing body tissues and organs.
Urgent Care means a sudden Injury or condition that:




Is severe enough to require prompt medical attention to avoid serious deterioration of
the Covered Person’s health
Includes a condition which would subject the Covered Person to severe pain that could
not be adequately managed without urgent care or treatment
Does not require the level of care provided in the Emergency room of a Hospital, and
Requires immediate outpatient medical care that cannot be postponed until the Covered
Person’s Provider becomes reasonably available.
Urgent Care Center is a medical facility (or clinic or medical practitioner office) that provides
treatment for Urgent Care. An Urgent Care Center primarily treats patients who have an Injury
or illness that requires immediate care but is not serious enough to warrant a visit to an
emergency room. It offers an alternative to certain emergency room visits for a Covered
Person who is not able to visit his or her Primary Care Provider or health care Provider in the
time frame that is felt to be warranted by their condition or symptoms. An Urgent Care Center
does not provide Emergency care, and is not appropriate for people who have life-threatening
conditions. A Covered Person experiencing these conditions should go to an emergency room.
Italicized words are defined in Section 3
18
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SECTION 4 – COVERAGE
General Conditions for Coverage
We will pay benefits for Medically Necessary Covered Services that, within 90 days of the date
of the Accident that caused the Injury, require the Covered Person to be treated by a Provider.
We will pay benefits for Medically Necessary Covered Services received due to that Injury, up
to the plan limits and benefit amount for Accident Medical Expenses Benefits at the percentage
appearing in the Schedule of Benefits. These benefits are payable only for charges incurred
within 52 weeks after the date of the Accident that caused the Injury.
Excess Provision
All other plans covering medical insurance benefits for Expenses received due to Injury will be
considered primary, except if the Covered Person is enrolled under the School’s Student
Health Policy, in which case this Certificate will be considered primary. This Certificate does
not include a coordination of benefits provision.
Accident Medical Expenses
For the purposes of this Certificate, Accident Medical Expenses means:
















Ambulance Expenses
Anesthesia Expenses
Blood Expenses - Transfusion or Dialysis
Dental Injury Expenses
Durable Medical Equipment Expenses
Home Health Care Expenses
Hospice Care Expenses
Hospital Expenses, or use of a walk-in clinic
Laboratory and X-Ray Outpatient Expenses
Physical and Occupational Therapy Expenses
Provider Services Expenses
Prescription Drug Expenses
Prosthetic and Orthotic Devices Expenses
Surgical Expenses (including Assistant Surgeon)
Accidental Heart & Circulatory Malfunction Treatment Expenses
Accidental Repetitive Motion Injury Treatment Expenses
Ambulance Expenses
 Ground, sea, and helicopter ambulance transportation for Emergency care.
 Airplane ambulance services (e.g., Medflight).
 Non-Emergency, Medically Necessary ambulance transportation between covered
facilities.
 Non-Emergency ambulance transportation is covered for Medically Necessary care
when the Covered Person’s medical condition prevents safe transportation by any other
means.
Italicized words are defined in Section 3
19
To contact Member Services, call 1-844-603-6192
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Other vehicles which do not meet this definition, such as ambulettes, are not Covered
Services.
We will pay benefits for ambulance services when the need for such services is a direct result
of an Injury.
Anesthesia Expenses
We will pay benefits for Medically Necessary anesthesia and the administration of anesthesia
when the need for such anesthesia is a direct result of an Injury.
Blood Expenses – Transfusion or Dialysis
Covered Services include charges incurred by a Covered Person for the transfusion or dialysis
of blood, including the cost of whole blood, blood components, and the administration thereof,
when the need for such expenses is a direct result of an Injury.
Dental Injury Expenses
Covered Services include charges incurred by a Covered Person for:



Services of a Dentist or dental surgeon for removal of one or more teeth as a result of
an Injury.
Hospital services and supplies received for a Stay required because of Your condition.
Expenses for dental work, surgery, and Orthodontic Treatment needed to remove,
repair, replace, restore, or reposition:
 Natural teeth damaged, lost, or removed, or
 Other body tissues of the mouth fractured or cut, and
Any such teeth must have been:
 Free from decay, in good repair and
 Firmly attached to the jawbone at the time of the Injury.
The Accident causing the Injury must occur while the Covered Person is covered under this
Certificate, and the treatment must be performed within 52 weeks of the Accident.
If crowns (caps) or dentures (false teeth) or bridgework or in-mouth appliances are installed
due to such Injury, then Covered Services include only charges for:



The first denture or fixed bridgework to replace lost teeth
The first crown needed to repair each damaged tooth, and
An in-mouth appliance used in the first course of Orthodontic Treatment after the Injury.
Not included are charges:
 To remove, repair, replace, restore, or reposition teeth lost or damaged in the course of
biting or chewing
 To repair, replace, or restore fillings, crowns, dentures, or bridgework
 For periodontal treatment
 For dental cleaning, in-mouth scaling, planning, or scraping
 For myofunctional therapy that is muscle training therapy, or training to correct or
control harmful habits
Italicized words are defined in Section 3
20
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
Non-surgical treatment of infection or diseases. This does not include those of, or
related to, the teeth.
Surgery needed to:
 Cut out cysts, tumors, or other diseased tissues.
 Alter the jaw, jaw joints, or bite relationships by a cutting procedure when appliance
therapy alone cannot result in functional improvement.
We will pay benefits for Dental Injury Expenses when the need for such expenses is a direct
result of an Injury.
Durable Medical Equipment Expenses
We will pay benefits for Durable Medical Equipment when the need for such expenses is a
direct result of an Injury. In order to be eligible for coverage, the equipment must also be the
most appropriate available amount, supply or level of service for the Covered Person in
question considering potential benefits and harms to that individual. We determine this. We
may decide that equipment is: (1) non-medical in nature, and (2) used primarily for nonmedical purposes. (This may occur even though that equipment has some limited medical
use.) In this case, the equipment will not be considered.
Home Health Care Expense
Covered Services are those performed by a Home Health Agency or other Provider in
the Covered Person’s residence. Home Health Care includes professional, technical, health
aide services, supplies, and medical equipment. Services are limited to unlimited visits per
year. We will pay benefits for Home Health Care Expenses when the need for such expenses
is a direct result of an Injury.
For purposes of this benefit, “Home Health Care” means health services and supplies provided
to a Covered Person on a part-time, intermittent, visiting basis in such Covered Person’s place
of resident while confined as a result of Injury. “Home Health Agency” means an agency that
is licensed as a home health agency by the state in which Home Health Care services are
provided, certified as such under Medicare, and approved as such by Us.
Hospice Care Expenses
Hospice care may be provided in the home or at a Hospice facility where medical, social and
psychological services are given to help treat patients with a terminal illness. Hospice services
include routine home care, continuous home care, Inpatient Hospice and Inpatient Respite.
To be eligible for Hospice benefits, the patient must have a life expectancy of six (6) months
or less, as confirmed by the attending Provider. Covered Services will continue if the Covered
Person lives longer than six (6) months.
Covered Services include Hospital Room and Board expenses incurred by a Covered Person
for the period of confinement as an Inpatient, including: expense for an Intensive Care Unit.
We will pay benefits for Hospital Expenses when the need for such expenses is a direct result
of an Injury.
Miscellaneous Hospital Expense includes, but is not limited to, expenses incurred during a
Italicized words are defined in Section 3
21
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Hospital Stay for:




Anesthesia and operating room
Laboratory tests and X-rays
Oxygen tent, and
Drugs, medicines, dressings.
Laboratory and X-Ray Outpatient Expenses
Benefits are payable for Covered Services incurred by a Covered Person for diagnostic Xrays, and laboratory services, incurred on an Outpatient basis. We will pay benefits for
Laboratory and X-Ray Outpatient Expenses when the need for such expenses is a direct result
of an Injury.
Physical and Occupational Therapy Expenses
Covered Services include charges incurred by a Covered Person for the following types of
therapy provided on an Outpatient basis:


Physical Therapy
Occupational Therapy
Expenses for Chiropractic Care are Covered Services payable if such care is related to
neuromusculoskeletal conditions and conditions arising from the lack of normal nerve and/or
joint function. Expenses for Physical and Occupational Therapy and Chiropractic Care are
Covered Services only if such therapies are a result of an Accident.
Physical therapy must be for rehabilitation only after an Accident. All other therapy must be
initiated within 6 months of the onset of symptoms. All therapy must be provided by a therapist
who is licensed in accordance with state law and practicing within the scope of his or her
license.
All equipment and supplies must be prescribed by a Provider.
We assume no responsibility for the outcome of any Covered Services or supplies. We make
no express or implied warranties concerning the outcome of any Covered Services and
supplies.
Provider Services Expenses
Covered Services include Inpatient and Outpatient charges incurred by a Covered Person for
the treatment of an Injury requiring Medically Necessary services provided by a physician or
registered nurse (RN).
Exception: If the services are in connection with surgery and the physician is the surgeon who
performed the surgery, no benefits are payable under this provision.
Prosthetic and Orthotic Devices Expenses
Covered Services include charges incurred by a Covered Person for: artificial limbs, or eyes,
and other non-dental prosthetic or orthotic devices, as a result of an Accident or Injury.
Italicized words are defined in Section 3
22
To contact Member Services, call 1-844-603-6192
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Covered Services do not include: eye exams, eyeglasses, vision aids, hearing aids,
communication aids, and orthopedic shoes, or other devices to support the feet.
We will pay benefits for Prosthetic and Orthotic Devices Expenses when the need for such
expenses is a direct result of an Injury.
For purposes of this benefit, a “Prosthetic Device” means an artificial device designed to
replace, wholly or partly, an arm or leg. An “Orthotic Device” means a custom-fitted or customfabricated medical device that is applied to a part of the human body to correct a deformity,
improve function, or relieve symptoms of a disease.
Prescription Drug Expenses
The benefit amount for each covered Prescription Drug or refill prescribed by a Network
Provider and dispensed by an in-network Pharmacy will be an amount equal to the Covered
Percentage of the in-network Pharmacy’s contracted rate.
The benefit amount for each Prescription Drug or refill dispensed by a non-network Pharmacy
will be an amount equal to the Covered Percentage of the non-network Pharmacy’s charge.
We will pay benefits for Prescription Drug Expenses when the need for such Expenses is a
direct result of an Injury.
This benefit is provided to cover Prescription Drug Expenses associated with Injury occurring
during the Contract Year. If, by reason of similar benefit provisions elsewhere contained, this
Certificate provides for reimbursement for the same charges, no benefits shall be payable
under those provisions. These benefits are in place of all other benefits of this Certificate.
Surgical Expenses
Covered Services include charges incurred by a Covered Person for Surgery provided by a
Hospital or on an Inpatient or Outpatient basis. When Injury requires two or more Surgical
Procedures which are performed through the same approach, and at the same time or in
immediate succession, Covered Services only include expenses incurred for the most
expensive procedure.
If the physician performs both the Surgical Procedure and the anesthesia service, benefits for
the anesthesia will be reduced by 50%. When Surgery is performed in the Outpatient
department of a Hospital, Covered Services include Hospital services provided within 24 hours
of the covered surgical procedure.
We will pay benefits for Surgical Expenses when the need for such expenses is a direct result
of an Injury.
Accidental Heart or Circulatory Malfunction Expenses
We will pay benefits for Accidental bodily injuries to a Covered Person, which are independent
of disease, illness or other cause occurring while this Certificate is in force, including heart or
circulatory malfunction that are diagnosed by a Provider and occur within 48 hours of
participating in a Covered Activity.
The Covered Person must present satisfactory evidence to Us that participation in a Covered
Italicized words are defined in Section 3
23
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Activity precipitated the Medical Necessity of treatment.
We will pay the Covered Percentage appearing in the Schedule of Benefits for the initial
treatment of the symptoms of a heart or circulatory malfunction.
If the symptoms are diagnosed as a heart or circulatory malfunction caused by the Covered
Person’s participation in a Covered Activity, We will also pay the Covered Percentage
appearing in the Schedule of Benefits for further treatment of the heart or circulatory
malfunctions. However, no further treatment will be covered if the symptoms are diagnosed as
disease, illness or other non- Accident cause.
For the purpose of this benefit, heart or circulatory malfunction means a cardiovascular
accident, stroke or other similar traumatic event.
Accidental Repetitive Motion Injury Expenses
We will pay benefits for Accidental bodily injuries to a Covered Person, which is independent of
disease, illness or other cause occurring while this Certificate is in force, including repetitive
motion injuries that are diagnosed by a Provider and occur within 90 days of participating in a
Covered Activity, subject to the Covered Percentage appearing in the Schedule of Benefits.
The Covered Person must present satisfactory evidence to Us that participation in a Covered
Activity precipitated the Medical Necessity of treatment.
For the purpose of this benefit, repetitive motion Injury means stress fracture, strain, shin
splint, Osgood Schlatter Disease, Chondromalacia, tendonitis, bursitis or heat stroke.
Italicized words are defined in Section 3
24
To contact Member Services, call 1-844-603-6192
Or see Our website at www.christiestudenthealth.com/stmarytx/
SECTION 5 – TERMINATION OF COVERAGE
TERMINATION OF COVERAGE
Insurance for a Covered Person will end on the first of these to occur:
(a) The date this Certificate terminates.
(b) The date on which the Covered Person withdraws from the School because of
entering the armed forces of any country. Premiums will be refunded on a pro-rata
basis when application is made within 90 days from withdrawal.
If withdrawal from the School is for other than entering the armed forces, no premium refund
will be made. Covered Persons will be covered for the Certificate term for which they are
enrolled, and for which premium has been paid.
Reimbursable expenses may be incurred beyond the date of Termination of Coverage, up to a
total of 52 weeks following the date of the Accident.
Italicized words are defined in Section 3
25
To contact Member Services, call 1-844-603-6192
Or see Our website at www.christiestudenthealth.com/stmarytx/
SECTION 6 – GENERAL PROVISIONS
ENTIRE CONTRACT; CHANGES. The entire contract is made up of: (i) this Certificate,
including the School’s application, and (ii) the individual applications, if any, of Covered
Persons. In the absence of fraud, a statement made by the Covered Person is considered a
representation and not a warranty. A statement made by the Covered Person may not be
used in any contest under this Certificate, unless a copy of the written instrument containing
the statement is or has been provided to the person making the statement or if the statement
was made by the Covered Person and the Covered Person has died or become incapacitated,
the Covered Person’s beneficiary or personal representative. This Certificate may be
changed at any time by written agreement between Us and the School. The consent of any
student or other person is not needed. All agreements made by Us are signed by one of its
executive officers. No other person can change or waive any of the Certificate terms or make
any agreement binding Us. The School will not have to give written approval of a change in the
Certificate if: (1) The School has asked for the change and We have agreed to it, or (2) the
change is needed so that the Certificate will conform to any law, regulation, or ruling of a
jurisdiction, that affects a person covered under this Certificate or the federal government.
INCONTESTABILITY. The validity of this Certificate may not be contested after the
Certificate has been in force for two (2) years. In the absence of fraud, a statement made by
any Covered Person may not be used in contesting the validity of the insurance with respect
to which the statement is made after the insurance has been in force before the contest for
two (2) years during the Covered Person’s lifetime and unless the statement is contained in a
written instrument signed by the Covered Person making the statement.
PREMIUMS. We set the premiums that apply to the coverage provided under this Certificate.
Those premiums are shown in a notice given to the School with or prior to delivery of this
Certificate. We have the right to adjust the premium rate on each anniversary date of this
Certificate, or when the terms of this Certificate are changed. The School will be given notice of
such premium adjustment at least 60 days before the date it is to take effect, unless the
change in Certificate terms is to take effect before the 60 days.
PAYMENT OF PREMIUMS. The School will pay premiums in advance. They may be paid at
Our Home Office or to its authorized agent. A premium is due to be paid on the first day of
each Certificate month. The School may change the number of premium payments as of a
premium due date. This needs Our written consent.
RENEWAL OF CERTIFICATE. With Our consent, this Certificate may be renewed for like
periods by payment of the renewal premium at the premium rate in effect at that time. This
renewal premium must be paid within the grace period. We also have the right to refuse to
renew this Certificate.
GRACE PERIOD. The premium due date will be negotiated by Us and the School. The grace
period of 31 days will be granted for the payment of each premium falling due after the first
premium. During that period, this Certificate shall continue in force. The School shall be liable
to Us for the payment of the premium for the period this Certificate continues in force.
Italicized words are defined in Section 3
26
To contact Member Services, call 1-844-603-6192
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MISSTATEMENT OF AGE. If the age of a Covered Person has been misstated, all amounts
payable under this Certificate will be such as the premium paid would have purchased at the
correct age.
INDEPENDENT CONTRACTORS. We do not provide health care services to Covered
Persons. Network Providers provide health care services to Covered Persons. Such Network
Providers are independent contractors and are not Our employees or agents for any purposes.
Italicized words are defined in Section 3
27
To contact Member Services, call 1-844-603-6192
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SECTION 7 - EXCLUSIONS AND LIMITATIONS
1)
Sickness, disease or illness expenses.
2)
Expense incurred as a result of preventive medicines, serums, vaccines or oral
contraceptive.
3)
Expense incurred for treatment of mental health and substance abuse disorders.
4)
Expense incurred for the treatment of alcoholism or drug addiction.
5)
Equipment such as: whirlpools, portable whirlpool pumps, sauna baths, massage
devices, over-bed tables, elevators, communication aids, vision aids, and telephone
alert systems.
6)
The repair or replacement of existing artificial limbs, prosthetic appliances, rental of
existing Durable Medical Equipment, orthopedic braces, or orthotic devices, unless the
purpose of modifying the item is due to Injury while participating in a Covered Activity
that has caused further impairment in the underlying bodily condition.
7)
Air travel via an aircraft owned, leased or operated by the School, or any aircraft owned,
leased or operated by an employee of the School on behalf of the School.
8)
Air travel while acting or training as a pilot or crew member. This does not apply if a
Covered Person temporarily performs pilot or crew functions in a life threatening
emergency.
9)
Expense for new or repair or replacement of dentures, bridges, dental implants, dental
bands or braces or other dental appliances, caps, inlays or onlays, fillings or any other
treatment of the teeth or gums, except for repair or replacement of sound natural teeth
damaged or lost as a result of an Injury up to the maximum appearing in the Schedule
of Benefits herein.
10)
New or replacement hearing aids, or hearing exams, unless an Injury has caused
impairment or further impairment of a Covered Person’s hearing.
11)
Expenses incurred beyond 52 weeks from the date of the Accident.
12)
Treatment for Injury to the extent benefits are payable under any state no-fault
automobile coverage or first party medical benefits payable under any other mandatory
no-fault law.
13)
Expense incurred for Experimental or Investigative procedures.
14)
Expenses incurred for blood or blood plasma, except charges by a Hospital for the
processing or administration of blood.
Italicized words are defined in Section 3
28
To contact Member Services, call 1-844-603-6192
Or see Our website at www.christiestudenthealth.com/stmarytx/
15)
Expense incurred by a Covered Person who is not a United States citizen for services
performed within the Covered Person’s home country, if the Covered Person’s home
country has a socialized medicine program.
16)
Expense incurred for acupuncture, unless services are rendered for anesthetic
purposes.
17)
Expense incurred for alternative, holistic medicine, and/or therapy, including but not
limited to yoga and hypnotherapy.
18)
Expense for injuries sustained as the result of a motor vehicle accident, to the extent
that benefits are payable under other valid and collectible insurance whether or not
claim is made for such benefits. This Certificate will only pay for those losses which are
not payable under the automobile medical payment insurance policy.
19)
Expense for the cost of supplies used in the performance of any occupational therapy.
20)
Expense for personal hygiene and convenience items such as air conditioners,
humidifiers. hot tubs, whirlpools, or physical exercise equipment, even if such items are
prescribed by a Provider.
21)
Expense for incidental surgeries and standby charges of a Provider.
22)
Expenses incurred for massage therapy.
23)
Expense for treatment of Covered Person who specializes in the mental health care
field, and who receives treatment as a part of their training in that field.
24)
Expenses for routine physical exams, including expenses in connection with well
newborn care, routine vision exams, routine dental exams, routine hearing exams,
immunizations, or other preventive services and supplies, except to the extent coverage
of such exams, immunizations, services or supplies is specifically provided in the
Certificate.
25)
Expense incurred for a treatment, service or supply which is not Medically Necessary,
as determined by Us for the diagnosis care or treatment of the Injury involved. This
applies even if prescribed, recommended or approved by the Covered Person’s
attending Provider or a Dentist.
26)
Expense incurred for eye refractions, vision therapy radial keratotomy, eyeglasses,
contact lenses (except when required after cataract surgery), or other vision or hearing
aids, or prescriptions or examinations except as required for repair caused by a covered
Injury.
27)
Expense incurred as a result of an Injury sustained while in the service of the Armed
Forces of any country.
28)
Expense incurred from an intentionally self-inflicted Injury.
Italicized words are defined in Section 3
29
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29)
Expense incurred from active participation in a riot, insurrection, or terrorism.
Italicized words are defined in Section 3
30
To contact Member Services, call 1-844-603-6192
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SECTION 8 – HOW TO FILE A CLAIM AND MEMBER SATISFACTION
Network Providers
You may get care from a Network Provider. If so, You do not have to submit claim forms. The
Network Provider will submit claim forms to Us for You. We will make payment directly to the
Network Provider.
Non-Network Providers
You may get care from a Non-Network Provider. If so, it may be necessary to file a claim form.
Claim forms are available from the School or Us (See “To Get Claim Forms” and “Time Limit
for Providing Claim Forms” below).
Hospital Admission or Day Surgery
You may get care from a Hospital that is a Non-Network Provider. In this case, have the
Hospital complete a claim form. The Hospital should submit the claim form directly to Us. If
You are responsible for any part of the Hospital bill, We will send You an explanation of
benefits statement. The explanation of benefits will tell You how much You owe the NonNetwork Hospital.
Outpatient Medical Expenses
When You receive care from a Non-Network Provider, You are responsible for completing
claim forms. (Check with the Non-Network Provider to see if he or she will submit the claim
directly to Us. If not, You must submit the claim form directly to Us.)
If You sign the appropriate section on the claim form, We will make payment directly to the
Non- Network Provider. If You are responsible for any portion of the bill, We will send You an
explanation of benefits statement. The explanation of benefits will tell You how much You owe
the Non-Network Provider.
If You do not sign the appropriate section on the claim form, We will make payment directly to
You. If You have not already paid, You will be responsible for paying the Non-Network Provider
for the services You received. If You are responsible for any part of the bill, We will send You
an explanation of benefits statement. The explanation of benefits statement will tell You how
much You owe the Non-Network Provider.
To Get Claim Forms
You can get claim forms from the School, or You can call the Member Services Department.
Notice of Claim
Written notice of a claim must be given to Us not later than the twentieth (20th) day after the
date of the occurrence or beginning of any loss covered by this Certificate. Failure to give notice
within the time prescribed will not invalidate or reduce any claim if it is shown that it was not
reasonably possible to give the notice within that time and notice was given as soon as was
reasonably possible. Notice given by or on behalf of You to Us at Christie Student Health,
Claims Department, 80 Hayden Avenue, Lexington, MA 02421 or to any authorized agent of
Us, with information sufficient to identify You, shall be deemed notice to Us.
Italicized words are defined in Section 3
31
To contact Member Services, call 1-844-603-6192
Or see Our website at www.christiestudenthealth.com/stmarytx/
Time Limit for Providing Claim Forms
We will furnish to the Covered Person making a claim or to the School for delivery to such
Covered Person making a claim the forms usually provided by Us for filing a proof of loss. If
the forms for a proof of loss are not provided before the sixteenth (16th) day after the date
We received notice of a claim under the Certificate, the Covered Person making the claim is
considered to have complied with the requirements of the Master Policy as to proof of loss on
submitting, within the time limit set in the Master Policy for filing proof of loss, written proof
covering the occurrence, character, and extent of the loss for which the claim is made.
Where to Forward Medical Claim Forms
Send completed claim forms to:
Cigna
PO Box 188061
Chattanooga, TN 37422-8061
You should submit a separate claim form for each family member.
Proofs of Loss
Written proof of loss must be provided to Us not later than the ninetieth (90th) day after the
date of loss. Failure to provide written proof of loss within such timeframe will not invalidate or
reduce a claim if it was not reasonably possible to provide written proof of the loss within that
time; written proof of the loss is provided as soon as reasonably possible; and unless the
claimant does not have the legal capacity to provide proof of loss, proof of loss is provided not
later than the first anniversary of the date the proof of loss is otherwise required.
Time of Payment of Claims
All benefits payable under this Certificate, other than benefits for loss of time, will be paid no
later than the sixtieth (60th) day after the date the proof of loss is received. Subject to written
proof of loss, all accrued benefits payable under this Certificate for loss of time will be paid at
least monthly during the period for which We are liable, and any balance remaining unpaid at
the end of such period will be paid as soon as possible after the proof of loss is received.
Payment of Claims
All benefits of this Certificate, other than benefits for loss of life, will be paid to You or Your
assignee. Benefits for loss of life will be paid to the beneficiary designated by You or Your
assignee or Your estate, if the designated beneficiary is not living at the time of death.
Physical Examinations and Autopsy
We have the right and opportunity to conduct a physical examination of an individual for
whom a claim is made when and as often as We reasonably require during the pendency of
the claim under this Certificate. In the case of death, We have the right and opportunity to
require that an autopsy be conducted, unless the autopsy is prohibited by law.
Change of Beneficiary
The right to change of beneficiary is reserved to the insured and the consent of the beneficiary
or beneficiaries shall not be requisite to surrender of this Certificate or to any change of
Italicized words are defined in Section 3
32
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beneficiary or beneficiaries, or to any other changes in this Certificate.
Pharmacy Expenses
You may obtain a prescription at a non-designated or out-of-network Pharmacy. If so, You
must pay for the prescription up front. Then, submit a claim for reimbursement. You can get a
Pharmacy claim form by calling the Member Services Department or see Our website at
www.christiestudenthealth.com/stmarytx/.
Member Satisfaction Process
Purpose
The purpose of this policy is to outline the requirements of the Covered Person appeal process
for administrative benefit coverage denials and Medical Necessity denials (which include
denials based upon Experimental or Investigative or unproven and similar exclusions) of
requested benefits. References to We, Us, or Our in this section may refer to our designee.
Who Can Appeal
A Covered Person, an individual acting on behalf of the Covered Person or the Covered
Person’s Provider of record can request, orally or in writing, an appeal of any Adverse Benefit
Determination that the Covered Person believes is not adequately addressed or resolved by
Our Member Services Department. The internal appeal process is provided at no cost to the
Covered Person or to the Covered Person’s authorized representative. However, the Covered
Person is only allowed one set of internal appeals per issue.
When a party initiates an appeal on behalf of the Covered Person, the Covered Person must
be aware of this representation and have authorized the representative to appeal on his/her
behalf. However, for Expedited/Urgent appeals, a Provider with knowledge of the Covered
Person’s condition is always deemed to act as the Covered Person’s representative. For all
other appeals, when a party, other than a Provider, initiates an Adverse Benefit Determination
appeal on behalf of a Covered Person, the Covered Person must be aware of this
representation and have authorized the representative to appeal on his/her behalf. If the
Covered Person does not authorize the representative to appeal on his/her behalf, the
Covered Person can reject the representation and withdraw the appeal request. Covered
Persons, who contact Us when they receive the decision notification that they did not authorize
the party to appeal on their behalf and want the opportunity to appeal the issue, will be allowed
their full appeal rights. If the Covered Person does not object to the representation, and
authorizes the party to represent the Covered Person to the conclusion of the appeal process,
the Covered Person will have exhausted his/her opportunity to appeal the same Adverse
Benefit Determination in the future. Covered Person authorization is not required for a
Provider to initiate an Adverse Benefit Determination appeal, as Providers have direct access
to this policy.
For all customers who request language services, We provide interpretation (oral) or
translation services (written) in the Covered Person’s preferred language to register an appeal
and to notify customers about their appeal per Our policy.
Italicized words are defined in Section 3
33
To contact Member Services, call 1-844-603-6192
Or see Our website at www.christiestudenthealth.com/stmarytx/
Appeal Process
This policy consists of a single level internal appeals process for resolving disputes regarding
pre/post-service Medical Necessity or Experimental or Investigative denials of requested
benefits. Examples include: any request to overturn a previous denial for prior authorization of
a health care service or supply if prior authorization is required by benefit plan terms (a “preservice appeal”); or a request for reimbursement of the costs incurred for a health care service
or supply (“post-service appeal”). The internal appeal process will include appeals based upon
rescissions of coverage.
In cases of urgent, emergency or life-threatening conditions, or if We do not adhere to internal
claim and appeals processes, You are deemed to have exhausted the process and can
proceed to external review, if available, and pursue other remedies under the law as
applicable.
The internal claim and appeal process will not be deemed exhausted if the violation was de
minimus, non-prejudicial, attributable to good cause of matters beyond Our control, in the
context of an on-going good-faith exchange of information, and not reflective of a pattern or
practice of non-compliance.
Additionally, the Covered Person is entitled, upon written request, to an explanation within ten
(10) calendar days, of Our basis for asserting that it meets the above standards so that the
Covered Person can decide whether to seek immediate review. If the Covered Person
requests immediate external review and is rejected by the IRO or court, the Covered Person
has the right to resubmit to Us for an internal appeal.
Time Limit to File an Appeal Request
We allow a Covered Person to request a single level appeal at any time after an Adverse
Benefit Determination. There is no time limit.
Timeframes for Acknowledgement of the Appeal
All turnaround times are based on day of receipt being day 0.
Single Level Pre-Service/Post-Service Appeals: Within 5 business days of receipt
Timeframes for Resolution of the Appeal
All turnaround times are based on day of receipt being day 0.
 Single Level Pre-Service/Post Service Appeals: Within 30 calendar days (including the
5 days for acknowledgment of complaint)
 Single Level (Voluntary) Expedited/Urgent Appeal: Within one (1) business day or
sooner
*No extensions available.
Notification Decision
Single Level Expedited/Urgent Care Appeal: (a) Oral – Immediate, not to exceed one (1)
business day or sooner from receipt of appeal request; (b) Written - Within 2 calendar days
Italicized words are defined in Section 3
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after oral notification
Single Level Pre-Service/Post-Service: Within the earlier of: (a) 2 calendar days of Adverse
Benefit Determination appeal decision; or (b) 30 calendar days from receipt of the Adverse
Benefit Determination appeal request.
Independent External Review
If the Covered Person is still not satisfied following completion of the single level internal
appeals process, the Covered Person, his/her representative, or the Covered Person’s
Provider of record has the option to submit the dispute for resolution (which is binding upon
Us) by an independent external reviewer. Moreover, a Covered Person may seek an
immediate appeal to an IRO without first pursuing and/or exhausting Our internal appeal
process when:



the Covered Person has a life-threatening condition;
We fail to meet Our internal appeal process timeline(s); and/or
the Covered Person had an urgent pre-service or concurrent care request to authorize
or certify a course of treatment denied as not Medically Necessary or as Experimental
or Investigative.
Appeal Reviewer Requirements
We will ensure that all appeals are adjudicated in a manner designed to ensure the
independence and impartiality of the persons involved in the decision.
Single level and Expedited Medical Necessity appeal decisions are reviewed by Provider(s)
not involved in any previous decision; have no disqualifying associations with the Covered
Person or Provider of record; and are not a subordinate of the individual involved in any
previous determination(s). Approval decisions can be made by a non-physician Provider,
including a pharmacist. A Physician Reviewer must be responsible for all Medical Necessity
denial decisions. The Physician Reviewer shall (a) hold an active unrestricted license to
practice medicine; (b) hold an unrestricted license to practice medicine in a state or territory of
the United States; (c) be board certified in the same profession as the treating Provider and in
the same or a similar specialty which typically manages the medical condition, procedure, or
treatment; (d) for each appeal case, attest to having the scope of licensure or certification that
typically manages the medical and/or behavioral condition, procedure, treatment or issue
under review, as well as current, relevant experience and/or knowledge to render a
determination for the case under review; and (e) unless expressly allowed by state or federal
law or regulation, be located in a state or territory of the United States when conducting an
appeal or appeals reconsideration.
If an appeal is denied, the Covered Person has the right to request that the denial be reviewed
by a Provider in the same or similar specialty as typically manages the condition, procedure, or
treatment under discussion. The request must be made within 10 business days of the denial.
The specialty review must be completed within 15 business days of your request for the
specialty review.
Italicized words are defined in Section 3
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Receipt of Additional Information
Any additional information received after the determination notice is sent will be considered in
the next appeal level. We reserve the right to reverse a denial decision at any point in that next
appeal level if warranted by new information, without completing all components (e.g., Same
or Similar Specialist reviews) of the appeal process.
We will provide to the Covered Person, free of charge, any new or additional evidence
considered, relied upon, or generated by Us in connection with the claim. This evidence will be
provided as soon as possible and sufficiently in advance of the date of the final notification to
give the Covered Person a reasonable opportunity to respond prior to that date.
We will provide to the Covered Person, free of charge, any new or additional rationale upon
which an adverse determination is based as soon as possible and sufficiently in advance of the
date of the final notification to give the Covered Person a reasonable opportunity to respond
prior to that date.
Definitions
Terms used in this section and not otherwise defined in Appendix A have the meanings set
forth below:
Appeal means a request to change a previous Adverse Benefit Determination. A Covered
Person, his/her representative or Covered Person’s Provider of record may appeal the
Adverse Benefit Determination.
Benefit Denial means a denial of service that is specifically excluded from the Covered
Person’s benefits plan.
Business Day means any day where We are open for business operations. Such definition
does not include any national holidays or days when operations are temporarily closed due to
extenuating circumstances (e.g. inclement weather).
Clinical Peer means a Provider who holds a non-restricted license in a state of the United
States in the same or similar specialty that typically manages the medical condition, procedure,
or treatment under review.
Expedited Medical Necessity Appeal is available when processing the appeal under the
standard timeframes might jeopardize life, health, or ability to regain maximum functionality of
the Covered Person or when requested due to failure to authorize a continuing inpatient
hospital stay. Medical Necessity decisions regarding acquired brain injury will be handled as
expedited appeals. Decision will be made within one working day or sooner from the date
received.
Initial Medical Necessity Determination means an initial determination that specific health
care services of covered medical benefits do or do not meet the Medical Necessity
requirements of the applicable benefit plan, or are excluded as Experimental or Investigative or
Italicized words are defined in Section 3
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unproven.
Prior Authorization/Pre-certification means a Medical Necessity determination that is made
prior to the intended delivery of the Inpatient or Outpatient health care services or supplies
under review or prior to the performance of any services.
Concurrent Review means a Medical Necessity determination that is made during the period
when the health care services or supplies are being provided to a Covered Person including a)
during Inpatient, intensive Outpatient or residential behavioral health, or b) during ongoing
ambulatory care.
Retrospective Review means a Medical Necessity determination of any service that has
already been received by the Covered Person.
Life threatening means a disease or medical condition for which the likelihood of death is
probable unless the course of the disease or condition is interrupted. When applying for review
by an IRO, the determination of a "life-threatening" condition is made by the Provider or
Covered Person using the prudent layperson standard.
Physician Reviewer means a Provider, including a psychiatrist, who is responsible for
reviewing and rendering a decision on the Adverse Benefit Determination appeal request. In
some instances, an addictionologist or psychologist may be used depending on the request
and the credentials of the requestor.
Pre-service appeal means a request to change an Adverse Benefit Determination for care or
service that the organization must approve, in whole or in part, in advance of the Covered
Person obtaining care or services. A Covered Person’s request for an appeal of a denial for
service excluded from the organization’s benefits package is a pre-service appeal if the
Covered Person has not received the requested services.
Post-service appeal means a request to change an adverse determination for care or
services that have already been received by the Covered Person.
Relevant document, record or other information means any document that was relied upon
in making appeal decisions and was submitted, considered, or generated in course of making
a determination.
Representative means a party that the Covered Person authorizes to initiate an appeal on
their behalf.
Rescission is a cancellation or discontinuance of coverage that has a retroactive effect. It
does not include a cancellation: (a) that has only a prospective effect; or (b) a retroactive
cancellation that is the result of non-payment of premium/contributions.
Same or Similar Specialist (a.k.a. Clinical Peer) means:
Italicized words are defined in Section 3
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Same specialty means a Provider with similar credentials and licensure as those who typically
treat the condition or health problem in question in the appeal.
Similar specialty means to a Provider who has experience treating the same problem as
those in question in the appeal, in addition to experience treating similar complications to those
problems.
Utilization Review means the processes and procedures through which Medical Necessity or
Experimental or Investigative determinations are made and appeals of Medical Necessity or
Experimental or Investigative determinations are considered.
Procedure
A.
Internal Review
1.
Single Level Standard (Written or Oral) Pre-Service or Post Service Medical
Necessity Appeal:
o
The standard Medical Necessity appeal process is initiated upon receipt
of an appeal request. An appeal request may be made orally or in
writing. The following parties may submit a request for an appeal:
(a) the Covered Person; (b) any party acting on behalf of the Covered
Person, or (c) the Covered Person’s Provider of record.
o
We will send a written acknowledgment letter to the Covered Person and
his/her representative (if representative initiated the request) or the
Covered Person’s Provider of record. The acknowledgment letter will
include the date We received the request for appeal; a description of the
internal appeals process; a consent to release information form and a
one-page Appeal form. For appeals filed by a party on behalf of the
Covered Person, the acknowledgment letter to the Covered Person will
request the Covered Person to immediately notify Us if the Covered
Person has not authorized the party to represent him or her in the
appeal process and whether the appeal request is to be withdrawn. We
will send a separate acknowledgement letter to the Covered Person so
that all required components/forms are sent to the Covered Person.
o
All relevant documentation (e.g., Medical Necessity criteria, benefit
coverage criteria) that was relied upon for the previous decision or that
will be considered for the appeal decision must be obtained. This
includes information from the Covered Person’s Plan. If additional
clinical notes and documentation are needed, an outreach call will be
made to the treating or ordering Provider. We will conduct a full and fair
review of the appeal request.
o
When a party, other than a Provider, initiates an Adverse Benefit
Determination appeal on behalf of the Covered Person, the Covered
Italicized words are defined in Section 3
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Person must be aware of this representation and have authorized the
representative to appeal on his/her behalf. If the Covered Person does
not authorize the representative, the Covered Person may contact Us to
notify Us that the party appealing on his or her behalf does not have
authorization and to withdraw the appeal. The Covered Person’s appeal
rights will be retained. A withdrawal letter will be sent to the Covered
Person confirming the withdrawal request. Covered Person
authorization is not required for a Provider to initiate an Adverse Benefit
Determination appeal.
2.
o
In the event that any new or additional evidence considered, relied upon,
or generated by Us in connection with the appeal, We will provide a copy
free of charge to the Covered Person and give them reasonable time to
review prior to making the appeal decision.
o
All Medical Necessity appeals will be reviewed by a Provider. Medical
Necessity appeals that cannot be approved by a nurse reviewer will be
reviewed by a medical director who: (a) is a Same or Similar Specialist;
(b) was not involved with any previous decision; (c) has no disqualifying
associations with the Covered Person or the Covered Person’s Provider;
and (d) is not the subordinate of a previous decision maker. If a
Physician Reviewer is used, the Physician Reviewer must hold an active
unrestricted license to practice medicine in the State of Texas and an
unrestricted license to practice medicine in a state or territory of the
United States.
o
Prior to issuing an adverse appeal determination, the Provider of record
will be offered a reasonable opportunity to discuss the plan of treatment
with a physician who is a Same or Similar Specialist prior to issuance of
the appeal adverse determination. Reasonable opportunity is defined as
at least one good faith attempt to contact the Provider of record during
normal business hours. The reasonable opportunity will be offered at
least one business day before adverse determinations related to
prospective review appeals, at least five business days before adverse
determinations related to retrospective appeals and prior to issuing
adverse determinations related to post-stabilization or concurrent review
appeals. The discussion will include at a minimum the clinical basis for
the denial.
o
Any approval decisions are implemented within 15 calendar days of
decision. Appeal record is closed within 5 business days of the date the
required action was taken.
Expedited: Voluntary Single Level (Written or Oral) Appeal
(Note: Only Pre-Service and Concurrent reviews are eligible for expedited
processing.)
Italicized words are defined in Section 3
39
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o
The Covered Person, the Covered Person’s Provider, or a party
appealing on behalf of the Covered Person may submit an oral or written
request for expedited appeal pertaining to denials of: emergency care;
care for a life threatening condition; and/or continued hospitalization
services.
o
The Covered Person may pursue an expedited independent external
review in lieu of an expedited appeal review.
o
We will determine if the appeal meets the criteria for processing as an
expedited/urgent appeal. An outreach call to the treating Provider may
be made if clarification or additional information is needed.
o
Medical Necessity decisions regarding acquired brain injuries will be
handled as expedited appeals.
o
If the appeal does not meet the criteria for expedited/urgent processing,
the Covered Person, his or her authorized representative, and/or the
Covered Person’s treating Provider will be notified by phone that the
appeal will be processed as a standard pre-service appeal.
o
If the appeal relates to an Adverse Benefit Determination involving a
medical condition of the Covered Person for which the timeframe for
completion of an expedited internal appeal would seriously jeopardize
the life or health of the Covered Person or would jeopardize the Covered
Person's ability to regain maximum function, and the Covered Person
has filed a request for an expedited internal appeal, the Covered Person
may request a simultaneous expedited external review.
o
No extension is available. The decision must be based on the
information available within one (1) business day or sooner.
o
In the event that any new or additional evidence considered, relied upon,
or generated by Us in connection with the appeal, We will provide a copy
free of charge to the Covered Person and give them reasonable time to
review prior to making the appeal decision.
o
All Medical Necessity appeals will be reviewed by a Provider. Medical
Necessity appeals that cannot be approved by a nurse reviewer will be
reviewed by a medical director who: (a) is a Same or Similar Specialist;
(b) was not involved with any previous decision; and (c) is not the
subordinate of a previous decision maker. If a Physician Reviewer is
used, the Physician Reviewer will, whenever possible, hold an active
unrestricted license to practice medicine in the State of Texas and an
unrestricted license to practice medicine in a state or territory of the
United States.
Italicized words are defined in Section 3
40
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3.
o
All relevant documentation (e.g., Medical Necessity criteria, benefit
coverage criteria) that was relied upon for the previous decision or that
will be considered for the appeal decision must be obtained. This
includes information from the Covered Person’s benefit plan. We will
conduct a full and fair review of the appeal request.
o
Prior to issuing an Adverse Benefit Determination appeal denial, the
Provider of record will be offered a reasonable opportunity to discuss the
plan of treatment with a physician who is a Same or Similar Specialist
prior to issuance of the appeal Adverse Benefit Determination.
Reasonable opportunity is defined as at least one good faith attempt to
contact the Provider of record during normal business hours. The
reasonable opportunity will be offered at least one business day before
Adverse Benefit Determinations related to prospective review appeals,
at least five business days before Adverse Benefit Determinations
related to retrospective appeals and prior to issuing Adverse Benefit
Determinations related to post-stabilization or concurrent review
appeals. The discussion will include at a minimum the clinical basis for
the denial.
o
Decision is communicated orally to the Covered Person or party
appealing on behalf of Covered Person, including the Covered Person’s
treating Provider.
o
A decision letter is mailed within two calendar days of oral
communication. The Covered Person is notified of an external
independent review for Medical Necessity.
o
Any approval decisions are implemented within 15 calendar days of
decision. Appeal record is closed within 5 business days of the date the
required action is taken.
Decision Letters
o
Written notification for all appeal decisions will be issued to the Covered
Person, the party authorized to appeal on behalf of the Covered Person,
or the Covered Person’s Provider of record.
o
All decision letters will identify the decision maker. The reviewing
physician’s specialty will be identified. Overturn (approval) decision
letters will include the approval decision date.
o
If decision notification letter (e.g., approval or denial) is sent by facsimile,
the same letter will not be sent by mail.
o
All Adverse Benefit Determination notices will include information
sufficient to identify the claim involved. Notices will include information
Italicized words are defined in Section 3
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regarding the availability of, and contact information for, any applicable
office of health insurance consumer assistance or ombudsman
established under the Public Health Service Act Section 2793.
o
Adverse Benefit Determination notices will include a statement regarding
the availability of language assistance services.
o
Upheld (denial) decision letters will be sent to the Covered Person and
his or her representative and will include:
(a)
a summary of the issue to illustrate understanding of the facts of
the case;
(b)
the decision and rationale in clear terms (principle reasons for the
determination);
(c)
reference to the language in the Certificate on which the decision is
based (exact quotes when appropriate);
(d)
a statement that the Covered Person is entitled to receive free
access to, and copies of, all documents, records and other
information pertinent to the appeal for benefits;
(e)
the name of the specific rule, guideline, or protocol relied upon;
(f)
a description of the additional appeal rights, if applicable, including
a statement of the Covered Person’s right to bring legal action
under Section 502(a) of ERISA, if Covered Person is covered by
ERISA;
(g)
if applicable, notice of the Covered Person’s right to submit a
complaint to the state regulator(s), including specific ERISA
disclosure language;
(h)
professional designation of the physician involved in the decision;
(i)
statement that the scientific or clinical judgment explanation that
was relied upon for the determination will be available upon
request;
(j)
Texas Department of Insurance’s toll-free number and address;
(k)
instructions and forms for appealing to independent review
organization for external review;
(l)
notice of opportunity to request specific diagnosis and treatment
codes submitted by the Provider and their meaning; and
(m) notice of the availability of oral translation services, as required
under federal law.
Appeal documentation will include:

Name and credentials/credential of the clinical peer completing the appeal
Italicized words are defined in Section 3
42
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

4.
review/decision.
Name of the patient, provider and/or facility rendering service.
Date of an appeal review, documentation of action taken, and final resolution.
Medical Necessity Same or Similar Specialty Requirements
A medical director of same or similar specialty must be responsible for all denial
appeal decisions that cannot be approved by a nurse reviewer or a behavioral
health care professional. The medical director must not be involved in the initial
decision or be the subordinate of the individual involved in the initial
determination.
5.
Identification of a Same or Similar Specialist
The following must be considered when determining the appropriate physician
specialty match:





B.
The specialty of the physician ordering the service
The specialty of the physician requesting the appeal
The specialty of the physician rendering the care or service
The service/care being reviewed for consideration on appeal
Based on an evaluation of the above, make the ‘closest’ specialty match
possible.
6.
If additional appeal requests are received after all internal and any applicable
external review options are exhausted, Our Appeal Coordinator will ask the
appealing entity to forward the request to the appropriate party (employer/plan
sponsor/plan administrator) for further review and consideration.
7.
If requested in writing, within one year of the previous determination decision, We
will provide, free of charge, reasonable access to or copies of all relevant
documents, records, or other information pertinent to the appeal determination.
External Reviews
An external level review is conducted by an Independent Review Organization (IRO) certified
by the Texas Department of Insurance (TDI). Any state-specific and accreditation mandates
related to this process are followed. Covered Persons are notified of the program annually.
The Covered Person, his/her authorized representative, or the Covered Person’s Provider will
be informed in an initial Medical Necessity denial letter and in the single-level appeal denial
letter of their right to an external review and the eligibility criteria for the external review. The
denial letters will also include the state required IRO Request Form.
The IRO review process will be initiated by the receipt of the state IRO Request Form
completed by the Covered Person, the Provider or their authorized representative.
Preliminary Review
Italicized words are defined in Section 3
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We will determine if the appeal meets one of the following criteria to qualify for an IRO:
(a)
(b)
(c)
(d)
Appeal of an Adverse Benefit Determination regarding a life threatening condition
(for life threatening conditions, the Covered Person or his or her Provider is
entitled to immediate appeal to IRO and is not required to comply with the
internal appeal process);
Appeal of an Adverse Benefit Determination that has been upheld by Us using
the internal appeals processes;
Appeal is requested by Us after a litigation claim is made by insured Covered
Person. Request must be made not later than the 14th day after the written
notice of the claim is received by Us;
A court orders a review as part of considering an action by a Covered Person or
his or her Provider against Us.
TDI interprets cosmetic procedures and Out of Network care to be administrative denials which
would not be eligible for the Texas IRO process.
We, or Our designee, immediately within one business day, will:
1.
2.
Review the request for completeness and determine if the Covered Person has
indicated this is a “life threatening” condition. The part of the form authorizing
medical release of information must be signed by the Covered Person or his or
her legal guardian before an IRO can be assigned. Incomplete forms will be
returned to the Covered Person or Us with an indication of the parts that still
must be completed. If the condition is “life threatening,” a call will be made to the
Covered Person and a form faxed or overnighted to secure the Covered Person’s
signature.
Submit the completed forms to TDI immediately upon receipt of the IRO request.
TDI Actions:
TDI will assign an IRO and notify Us and the Covered Person within one working day of receipt
of the request.
Our Actions:
Within one working day of receipt of IRO request form, We will compile (1) any medical records
of the Covered Person in the possession of Us that are relevant to the review; (2) any
documents used by Us in making the determination to be reviewed by the IRO; (3) the written
notification to the appealing party of the determination of the appeal; (4) any documentation
and written information submitted to Us in support of the appeal. Not later than the third
working day after We have received the request for the IRO review, We will send the packet to
the IRO.
IRO Actions:
Non-Life Threatening Conditions: Not later than the earlier of the 15th day after receipt of all
Italicized words are defined in Section 3
44
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information necessary to make the determination, or the 20th day after the date the IRO
receives the request that the determination be made, the IRO will review and make a
determination. Following the determination, the IRO will notify:
(a) the Covered Person or person acting on the Covered Person’s behalf
(b) the Covered Person’s provider of record
(c) the utilization review agent
(d) the payor
(e) TDI
Non-Life Threatening notification will be mailed or otherwise transmitted not later than the time
frames listed above.
Life Threatening Conditions: The IRO must issue an urgent care decision to Us and the
Covered Person and the Covered Person’s Provider not later than the third (3rd) day after the
IRO’s receipt of information necessary to make a determination. Following the determination,
the IRO will notify:
(a) the Covered Person or person acting on the Covered Person’s behalf
(b) the Covered Person’s provider of record
(c) the utilization review agent
(d) the payor
(e) TDI
Life Threatening notification will be by telephone followed by facsimile, electronic mail or other
method of transmission not later than the time frames listed above.
Our Follow-Up Actions:
We will assure that the Covered Person obtains any additional services when indicated by an
IRO review determination
Notice to Covered Persons
Questions regarding Your coverage should be directed to:
Christie Student Health
80 Hayden Avenue
Lexington, MA 02421
Bills from Providers
Occasionally, You may receive a bill from a Non-Network Provider for Covered Services.
Before paying the bill, contact the Member Services Department.
If You do pay the bill, You must send it to the Member Reimbursement Medical Claims
Department.
Italicized words are defined in Section 3
45
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The address for the Member Reimbursement Medical Claims Department is listed on the
Member Reimbursement Medical Claim Form.
Note: You must contact Us regarding Your bill(s) or send Your bill(s) to Us within 90 days
from the date of service, or as soon as reasonably possible. If You do not, the bill cannot be
considered for payment, unless You are legally incapacitated. In no event, except in cases of
legal incapacitation, can bills be considered for payment after a period of 1 year.
We reserve the right to be reimbursed by the Covered Person for payments made due to Our
error.
IMPORTANT NOTE:
We will directly reimburse You for Covered Services You receive from most NonNetwork Providers. Some examples of these types of Non- Network Providers
include:
•
•
radiologists, pathologists, and anesthesiologists
who work in hospitals, and
Emergency room specialists.
You will be responsible to pay the Non-Network Provider for those Covered
Services.
For more information, call Our Member Services Department, or check Our
website at www.christiestudenthealth.com/stmarytx/.
Limitation on Actions
An action at law or in equity may not be brought to recover on this Certificate before the sixtyfirst (61st) day after the date written proof of loss is filed as required under this Certificate or
after the third (3rd) anniversary of the date on which written proof of loss is required under this
Certificate to be filed.
Italicized words are defined in Section 3
46
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