2019/2020 Group Brochure Group/Certificate Number: EPSWN00243917 IMG 24-Hour Assistance Toll-free: (855) 731-9445 Direct Dial: + 1 (317) 927-6806 or via email at: [email protected] Using Your Insurance If you need to seek medical treatment, please be sure to seek care appropriately for the condition/situation that you are experiencing. Choosing the correct medical provider will make Claims your experience much better, and it will make the billing and payment process much smoother. When seeking medical care please use Here are some guidelines for choosing appropriate medical care. the following guidelines to submit your claims to the insurance company: Non-Emergency Care Inside the USA - If you sought treatment If you do not have a medical emergency, you SHOULD go to a walk-in clinic or from an in-network provider, and local doctor who can assist you with your medical needs. You SHOULD provided your insurance ID card at the NOT go to the Emergency Room (ER). You can call IMG prior to receiving any time of treatment, they should be able to treatment and they will assist in locating a medical provider, or you can visit the bill the IMG claims team directly with no online provider search tool in your student zone. Examples of non-emergency payment up front. care include cold, flu, minor injuries and sickness. If you have received any medical bills after treatment or paid for any services Emergency Care up front to a provider, please complete a The Emergency Room (ER) is designed for medical emergencies. If you need claim form and email these documents emergency care for any reason, please get to the nearest Emergency Room (ER) to the claims email for processing. or call the emergency services (911 in the USA) for immediate treatment. It is Outside the USA - When outside the also important to make sure you contact IMG as soon as possible if you have USA, please seek treatment from a been hospitalized. provider that is nearest to you, pay for As with anything, we ask you to use your judgment with a situation. If you feel the services upfront and then submit a you need immediate emergency attention, please do not delay and go straight to claim for reimbursement. the Emergency Room. However if you are unsure, or your condition is not Prescription Medications - Any severe, then either call the emergency services for assistance or visit a local medications that you have been doctor, urgent care center or walk-in clinic in your area. prescribed will need to be paid for at the Please Note – an additional $200 Deductible will apply for each Emergency time of purchase and added to any Room visit for an illness which does not result in a direct Hospital admission. claims you are submitting. Injuries are not subject to the deductible Claim Forms You can download a copy of the claim ID Card form from the student zone and submit it It is extremely important that you carry your insurance ID card with you at all with your receipts to: times as this will identify to the provider treating you who your insurance is with. Your ID card will be given to you before you travel and should be kept with you at Email - [email protected] all times. (recommended) Providers Fax: (+1) 317 655 4505 Whether inside or outside the USA you have the freedom of choice to visit any International Medical Group provider you wish, however you are strongly encouraged to visit medical Claims Department providers who are part of the insurance plan network. This will allow direct billing PO Box 88500 and can remove the need for you to pay up front for medical expenses. Indianapolis, IN 46208-0500, USA Inside the USA, you can search for a network providers online and either call for an appointment or for urgent care clinics, just walk up for treatment. Outside the USA, you can still search for providers online or find the nearest provider to you, Claims Update seek treatment and pay for those expenses up front. You can then claim these MyIMG in your Student Zone will allow back at a later time. you to login and view all your claims activity and contact the claims team To search for providers, please visit your student zone. directly with any questions. You can also email the claims team at Pre-Certification [email protected] for an update on any claims that have been The following must always be pre-certified: (a) Chemotherapy, (b) Extended Care submitted. Facility, (c) Home Nursing Care, (d) Inpatient Hospitalization, (e) Interfacility Ambulance Transfer, (f) Radiation Therapy, (g) Surgery or Surgical procedure, (h) Medical Evacuation, (i) Return of Mortal Remains and (j) Emergency Reunion. To pre-certify, please contact IMG as soon as possible and before any treatment or services have been obtained. Failure to pre-certify will see a 50% reduction in benefits, with a maximum penalty of $1,000. Benefit Summary Plan Benefits Coverage Student Zone Maximum Limit $200,000 The student zone is your one-stop resource for information, advice and assistance with Maximum Limit per injury/illness $200,000 your insurance plan. Deductible $100 per injury/illness It includes: Coinsurance After the deductible, the plan pays 100% Video Overviews Inpatient and Outpatient Services Subject to the deductible - unless stated Healthcare Tips Eligible Medical Expenses 100% coverage Physician/ Specialist Visit 100% coverage/ 1 visit per day Seeking Treatment Urgent Care 100% coverage, $50 copayment (not subject to deductible) Provider Search Hospital Emergency Room 100% coverage (Illness with no direct hospital admission subject to $200 Claim Forms deductible, injuries not subject to additional deductible) Hospitalization / Room & Board 100% coverage MyIMG Intensive Care 100% coverage Outpatient Surgical 100% coverage MyDocuments Prescriptions 100%/ 90 day dispensing maximum Surgery 100% coverage Your student zone is accessible at: Physical Therapy 100% coverage/ 1 visit per day Medical order or Treatment plan required http://egi.zone/janus Emergency Services Not Subject to the deductible - unless stated Emergency Medical Evacuation $100,000 Maximum Limit 24-hour Assistance Return of Mortal Remains $50,000 Maximum Limit IMG are available 24-hours a day to assist you with your insurance needs, including Emergency Reunion $2,500 Maximum Limit pre-certification, claims, emergency Political Evacuation $10,000 Maximum Limit evacuation and much more. Interfacility Ambulance Transfer 100% coverage You can contact IMG at: Emergency Local Ambulance 100% coverage Toll-free: (855) 731-9445 (Illness covered when direct hospital admission, subject to deductible) Direct Dial: + 1 (317) 927-6806 Other Services [email protected] Not Subject to the deductible - unless stated Accidental Death & $25,000 Principal Sum Dismemberment Dental Treatment Accident - Up to Maximum Limit Unexpected Pain - $200 Maximum Limit Traumatic Dental Injury 100% coverage Subject to deductible Sports $5,000 Maximum Limit for contact sports, 100% for non- contact, leisure and recreational sports Terrorism $50,000 Trip Interruption $5,000 Please note: This document is being provided for informational purposes only and does not supersede in any way the terms in the governing documents for your insurance plan. Please visit the student zone for a copy of your insurance certificate which includes the full plan wording and exclusions. Plan Exclusions Except as expressly provided for in the BENEFIT SUMMARY, all Charges, costs, expenses and/or claims incurred by the Insured Person, and any claim for death or dismemberment benefits, and directly or indirectly relating to or arising or resulting from or in connection with any of the following acts, omissions, events, conditions, Charges, consequences, claims, Treatment (including diagnoses, consultations, tests, examinations and evaluations related thereto), services and/or supplies are expressly excluded from coverage under this insurance, and the Company shall provide no benefits or reimbursements and shall have no liability or obligation for any coverage thereof or therefor: 1. War; Military Action 17. Charges or Treatment for cosmetic or aesthetic reasons, except for 2. Terrorism reconstructive Surgery when such Surgery is Medically Necessary and is directly 3. Pre-existing Conditions related to and/or follows a Surgery which was covered under this insurance 4. Maternity and Newborn Care 18. Elective Surgery or Treatment of any kind 5. Mental and Nervous Disorders, Substance Abuse 19. Charges incurred for any Treatment or supply that either promotes or prevents or 6. Preventative Care attempts to promote or prevent conception, insemination (natural or otherwise) 7. Charges for any Treatment or supplies that are: or birth, including but not limited to: artificial insemination; oral contraceptives; 7.1. not incurred, obtained or received by an Insured Person during the Treatment for infertility or impotency; vasectomy, or reversal of vasectomy; Period of Coverage sterilization; reversal of sterilization; surrogacy or abortion 7.2. not presented to the Company for payment by way of a completed 20. Charges incurred for any Treatment or supply that either promotes, enhances or Proof of Claim within one hundred eighty (180) days from the date such corrects or attempts to promote, enhance or correct impotency or sexual Charges are incurred dysfunction 7.3. not administered or ordered by a Physician 21. Any Illness or Injury sustained while taking part in, practicing or training for: 7.4. not Medically Necessary for the diagnosis, care or Treatment of the Amateur Athletics (except as otherwise expressly provided for in this insurance); physical or mental condition involved. This also applies when and if Professional Athletics; or athletic activities that are sponsored by any Governing they are prescribed, recommended or approved by the attending Body or Authority including the National Collegiate Athletic Association, any other Physician collegiate sanctioning or Governing Body or the International Olympic Committee 7.5.