BCSMD 2013-2014 Form #4 BERRY COLLEGE ATHLETIC DEPARTMENT Excess Athletic Insurance Policy

Please read the following information on Berry’s Excess Athletic Insurance. Please retain a copy of the policy information for your records, and return the Excess Athletic Insurance Policy with proper initials and the Excess Athletic Insurance Policy Agreement properly signed to the Sports Medicine Department.

INSURANCE COVERAGE Berry College provides excess insurance over and beyond the athlete’s primary insurance up to a set policy limit for the athletes’ protection IN THE EVENT INJURIES ARE SUSTAINED DURING SCHEDULED/SUPERVISED PRACTICES/GAMES. This policy also covers the athletes while traveling directly to or from a scheduled event. Berry College will assist the student athlete in getting proper medical attention for injuries, but insurance coverage will not apply UNLESS THE INJURY IS A DIRECT RESULT OF A SCHEDULED /SUPERVISED PRACTICE OR GAME. Berry College does not make the final determination as to coverage by the excess insurance and has no authority to determine such rulings. Any charges not covered are the student/insured’s responsibility. The NCAA does not permit Berry College or any college to provide coverage or pay any bills incurred for expenses related to illnesses or injuries which are not sustained as a direct result of an accident or injury in the Berry College Intercollegiate Athletic Program. Berry College will only approve secondary payment on medical care arranged/approved by the Director of Sports Medicine. Injury means bodily injury caused by an accident that occurs while the policy is in force to the person whose injury is the basis of the claim; occurs while such person is participating in a covered activity; and results directly and independently of all other causes in a covered loss. This policy provides a two-year benefit period. This means the athlete has two years from the date of injury to receive any treatment. The athlete also has two years from the date of service for any injury to turn in any bills incurred to Garner & Glover Company. In the event of surgery, the Berry College Sports Medicine Department will only be financially responsible if said surgery is done with consent of the Director of Sports Medicine and Team Physicians. Without written permission and approval, the total financial responsibility falls upon the student athlete. In addition, it is the athlete’s responsibility to request a copy of all surgical post operation notes and that notes are to be sent the Sports Medicine Department. No post operation follow-up care or rehabilitation can be provided before all of the medical records are received. If an athlete desires to see a healthcare provider outside of our Team Physicians, they must consult and get approval from the Director of Sports Medicine. This includes new injuries or second opinions of any kind. Excess insurance provided through Berry College only covers injuries that occur during official practices and events scheduled and supervised by the head coach, assistant coach, graduate assistant coach, or appropriate Athletic Department personnel. Injuries or exacerbation of any pre-existing condition which occur at any practice or event organized by others not sanctioned by the NCAA or Berry College are excluded from Berry College’s excess insurance policy and will not be covered.

______Please initial that you have read and understand the above information. This includes both Policy Holder and Student-Athlete.

POLICY EXCLUSIONS: Benefits are not payable under this policy for any of the following or loss that results there from: 1. Routine physical examinations and routine testing; preventive testing or treatment; screening examinations or testing in the absence of injury; referrals resulting from physical examination in order to be cleared. 2. Eye examinations; prescriptions or fitting of eyeglasses and contact lenses; eyeglasses, contact lenses or other Treatment for visual defects and problems, except as required as a result of a covered Injury. "Visual defects" means any physical defect of the eye that does or can impair normal vision. 3. Dental care or treatment other than care of sound, natural teeth and gums required due to an injury resulting from an accident while the covered person is insured under this policy, and rendered within 24 months of the accident. 4. War or any act of war, declared or undeclared; or while serving in the armed forces of any country (a pro- rata premium will be refunded for such period of service).

1 BCSMD 2013-2014 Form #4 5. Participation in a riot or civil disorder; fighting or brawling, except in self-defense; commission of or attempt to commit a felony. 6. Suicide, attempted suicide or intentionally self-inflicted Injury while sane or insane. 7. Injury or death contributed to by the use of drugs or alcohol, unless administered by a physician. 8. Participation in, practice for, or orthopedic equipment and appliances used for, club sports, semi- professional sports or professional sports (except as specified in the Coverage Descriptions). 9. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing or flight in any type of aircraft, except while riding as a fare-paying passenger on a regularly-scheduled airline. 10. Treatment, services or supplies provided by a hospital or facility owned or run by the United States Government, unless a charge is made for such services in the absence of insurance; or in a hospital which does not unconditionally require payment. 11. Injury covered by Worker's Compensation or Employer's Liability Laws, or by any coverage provided or required by law (including, but not limited to group, group type, and individual automobile "No-Fault" coverage). 12. Treatment or services provided by any member of the covered person's immediate family; or for which no charge is normally made. 13. Treatment, services or supplies provided, normally without charge, by the school's health and wellness center or its employees, or physicians who work for the school. 14. Treatment, services or supplies provided or paid for by any governmental program or law. 15. Treatment of sickness, condition, disease, ailment, or infections (except pyogenic infections or bacterial infections which result from the accidental ingestion of contaminated substances).

______Please initial that you have read and understand the above information. This includes both Policy Holder and Student-Athlete.

DOCTOR, HOSPITAL, AND ALL OTHER MEDICAL VISITS The insurance coverage provided by Berry College will not be responsible for charges incurred by a student-athletes’ visit to a medical facility unless the Director of Sports Medicine has approved the visit.

______Please initial that you have read and understand the above information. This includes both Policy Holder and Student-Athlete.

INSURANCE AUTHORIZATION The following is a step-by-step procedure you need to follow in order to ensure the greatest likelihood of coverage. 1. Notify the Sports Medicine staff as soon as reasonably possible but not less than 72 hours following the injury or onset of illness. If an injury is not reported within 72 hours, Berry College will offer no support for processing insurance claims. This includes when an athlete is traveling for Christmas or spring break. Student athlete must take the Berry College Excess Insurance card in addition to their Primary Insurance card to every healthcare provider’s visit for qualifying injuries.

______Please initial that you have read and understand the above information. This includes both Policy Holder and Student-Athlete.

2. Fill out appropriate claim forms for excess insurance that you will receive from the Athletic Trainer assigned to your sport. Please initial in ALL requested areas. 3. Notify primary insurance agent to initiate claim. It is your responsibility to get pre-approval for all potential claims if required. 4. Verify that the service provider (hospital, physical therapy clinic, emergency room, etc.) has filed charges with your primary insurance. If not, provide them with the primary’s information and confirm charges have been filed.  All claims will be filed on the student athlete’s primary insurance first.  Specific information the provider will need includes, but is not limited to: 2 BCSMD 2013-2014 Form #4 Patient name Social Security Number Date of birth Referring physician Referral form Insurance information (Including point of contact)  In most cases, the provider will bill directly to the primary insurance. However, it is your responsibility to ensure this happens.  Precertification may be required, therefore it is recommended that you contact the insurance provider before initial treatment if possible.  For certain services, co-payments may be required. 5. If any bills remain after processing by the Primary Insurance Company, the remaining bills and EOB’s should be sent directly to the following address:

Sports Medicine Department P.O. Box 5011 Mount Berry, Georgia 30149 (706) 368-6331 (Phone)

PRESCRIPTION AUTHORIZATION You must have written authorization from the Director of Sports Medicine to have a prescription filled for injuries provided by the policy. If authorization is not received, the Athletic Department cannot be held responsible for excess coverage of the bill. Also, Aetna requires a payment receipt, pharmacy print out, and explanation of benefits.

REPORTING AN INJURY Report injuries immediately after they occur or have your coach contact an athletic trainer for you, who will take the necessary steps. It is necessary to report an injury as soon as reasonably possible but not less than 72 hours following the injury or onset of illness to the Sports Medicine staff who can provide proper care. If an injury is not reported within 72 hours, Berry College will offer no support for processing insurance claims. This includes when an athlete is traveling for Christmas or spring break.

3 BCSMD 2013-2014 Form #4 Excess Insurance: Description of Benefits Intercollegiate Athletic Accident Coverage Benefit Outfit Plan I-B, Berry College, 2013-2014 **Benefits reflect 2013-2014. Subject to change based on new agreement with insurance company.**

DOCTOR FEES Charges by physicians for medical and surgical treatment (physical therapy accepted)…………… ………………………...…………………………….…………………100% of Usual and Customary Expense

ASSISTANT SURGEON……………………………………………………….100% of Usual and Customary Expense

ANESTHESIA SERVICES OR CRNA..………………………………………100% of Usual and Customary Expense

HOSPITAL 1. Hospital Room and Board, the average semi-private room rate………100% of Usual and Customary Expense

2. Other Hospital Expense (inpatient or outpatient)- including operating room, drugs, laboratory, anesthesia, supplies, and charges of registered professional nurse while hospital confined……Usual and Customary Expense Up to a maximum of $2,000 for First day- $1,000 Each Day Thereafter

PHYSICAL THERAPY Coverage for diathermy, ultrasonic, whirlpool, or heat treatments, adjustments, manipulation, massage, or any form of physical and/or office visit connected therewith, shall be limited to………………………………. ………………………………………………………………………………$50.00 per visit with a maximum of $1000.00 per claim

AMBULANCE EXPENSE (Ground & Air Transportation)………...…………100% of Usual and Customary Expense

X-RAYS- INCLUDING INTERPRETATION (MRI’s & CAT scans)……. ..100% of Usual and Customary Expense

DENTAL FEES (Including Braces, Caps, and Bridges)……………………...... 100% of Usual and Customary Expense

LABORATORY, INJECTIONS, & PATHOLOGY…………………………100 % of Usual and Customary Expense

ORTHOTICS PRESCRIBED FOR REHABILITATION OF INJURY………...…….Maximum of $200.00 Per Claim

PRESCRIPTION DRUGS, CRUTCHES, WHEEL CHAIR RENTAL.……100% of Usual and Customary Expense

HEAT EXHAUSTION, HEAT PROSTRATION, FAINTING……………...100% of Usual and Customary Expense

DURABLE MEDICAL EQUIPMENT………………………………………………..….Maximum of $300 Per Claim (Hearing Aids, Eye Glasses, Contact Lenses)

HOME HEALTH CARE………………………………………………………...$50 per visit, with a maximum of $500 Per Claim

DIAGNOSTIC TESTING (Nerve Studies, Venous Studies, EMG)………………………….$200 Maximum Per Claim

PAIN MANAGEMENT AND SERVICES CONNECTED THEREWITH INCLUDING INJECTIONS……………………….……$500 Maximum Per Claim

OPTIONS TO STANDARD PLAN OF COVERAGE AETNA INSURANCE COMPANY

1. Expanded Medical Benefits: Repetitive motion injuries, strains, hernia, tendonitis, bursitis, and heat exhaustion (except as specifically stated) not related to a specific Injury. Heart and/or circulatory malfunction resulting from participation in a Covered Activity such as stroke, heat exhaustion (except as specifically stated), heart attack, and brain circulatory malfunctions. 2. Pre-existing conditions provides coverage for re-aggravation or complication of prior injury.

4 BCSMD 2013-2014 Form #4 BERRY COLLEGE ATHLETICS DEPARTMENT Excess Athletic Insurance Policy Agreement

MEDICAL INFORMATION AUTHORIZATION  I hereby authorize Berry College and Aetna/Garner & Glover Company to inspect or secure history records, laboratory reports, diagnoses, x-rays, and any other data covering this and/or previous confinements and/or disabilities. A photostatic copy of this authorization shall be deemed as effective and valid as the original.  I hereby authorize Berry College to release any medical, psychiatric, infectious disease, or alcohol/drug-related information to my referring physician and any insurance company with whom authorization is valid until such time as all medical bills related to my treatment have been paid. I further understand that I can withdraw this consent for release of information at any time prior to this expiration date except to the extent that action has been taken in reliance hereon.

HMO or PPO MEMBERS PLEASE NOTE : Aetna provides coverage for injuries sustained during a Berry College supervised practice or event only to the extent such charges are in excess of coverage provided by the athlete’s primary insurance company. If the primary insurance carrier is a PPO, HMO or otherwise maintains a list of approved physicians or facilities for any care necessary it is the athlete’s responsibility to ensure compliance and use providers that are approved by these organizations. If the athlete fails to use an approved provider for any reason and bills for expenses of treatment remain outstanding payment of such bills will be the sole responsibility of the athlete. Aetna may not provide excess coverage if the athlete does not follow the guidelines of his/her primary insurance.

FINANCIAL AGREEMENT: This coverage is written on an excess basis, which means any FAMILY OR GROUP INSURANCE PLAN MUST CONTRIBUTE ITS MAXIMUM BEFORE THIS COVERAGE HAS ANY LIABLITY. This is supplemented coverage designed to pay any balances left by the family or group insurance plan if the charges are within a customary range for services rendered.

BOTH SIGNATURES ARE REQUIRED UNLESS ATHLETE IS THE NAMED INSURED/POLICYHOLDER ON PRIMARY INSURANCE I hereby assume full responsibility for all charges related to professional services rendered by the health care facility referred by the Berry College Sports Medicine Department. I understand that these charges are my responsibility unless the services are deemed “paid in full” as a result of a contractual agreement between the referred health care facility and my insurer. ***I have read, understand, and will comply with the Berry College Excess Athletic Insurance Policy.*** Student Athlete’s name (print):______

Student Athlete’s signature: ______Date: ______

Policy Holder (Print name):______

Policy Holder Signature: ______Date: ______

5