Today’s LectureU of I Student Injury and Sickness

Insurance - Undergraduate Plan2007-2008Coverage

Deductibles, Coinsurance and Limits

Examples

Maximum Amount Payable

Aggregate

$200,000 for each Injury or Sickness

Psychiatric and Substance Abuse Treatment $20,000 per lifetime

Intercollegiate, Club and Intramural Sports Injuries

$75,000 per injury

In-Hospital Expense Benefit

$100 Deductible

80% of next $10,000

100% of balance of room and board and other hospital expenses incurred

In-Hospital Expense BenefitExample

In hospital for 10 days at $500 per day room and board.

Total charge: 10 x $500 = $5000

Deductible 100

80% of first $10,000 4900 = 3920

Amount payable = $3920

In-Hospital Expense BenefitExample 2

In hospital for 30 days at $500 per day room and board. How much does the U of I Student Plan pay?

A) 0

B) 10,000

C) 11,920

D) 12,900

E) None of the above

Pre-Admission TestingIf testing is performed within 7 days of the surgery, it is included under Hospital Expense Benefit.Otherwise, it would be considered an Outpatient Miscellaneous Expense Benefit.Example:

Tests performed on October 7Surgery on October 10Costs included in In-Hospital Expense BenefitIf no surgery was performed, or if it was performed after October 14, then it would be considered an Outpatient MiscellaneousExpense

Surgical Expense Benefit

Lower of:

80% of Usual and Customary or

80% of Actual Charge

Surgical Expense Benefit - Example

You have surgery and the surgeon charges you $10,000. The Usual and Customary fee is $12,000. How much does the U of I Student Plan pay?

A) 0

B) 8,000

C) 9,600

D) 10,000

E) None of the above

Assistant Surgeon Expense Benefit

Lower of:

80% of Usual and Customary or

80% of Actual Charge

Assistant Surgeon Expense Benefit Example

You have surgery and an assistant surgeon charges $3000 (Usual and Customary). How much does the U of I Student Plan pay?

A) 0

B) 2000

C) 2400

D) 2500

E) None of the above

Anesthesia Expense Benefit

Lower of:

80% of Usual and Customary or

80% of Actual Charge

Anesthesia Expense Benefit - ExampleDuring surgery, an anesthetist administers anesthesia. You are charged $6000. The Usual and Customary charge is $5000. How much does the U of I Student Plan pay?

A) 0

B) 4,000

C) 4,800

D) 5,000

E) None of the above

In-Hospital Physician’s Expense Benefit

Lower of:80% of Usual and Customary or80% of Actual Charge

Limited to 1 visit per dayIf in Intensive Care Unit, pays 50% (not 80%)

In-Hospital Physician’s Expense Benefit - Example

You are hospitalized for 2 days; the doctor visits you once each day, charging $200 for each visit (U&C). How much does the U of I Student Plan pay?A) 0B) 160C) 200D) 320E) None of the above

Outpatient BenefitsIncludes the following benefits (page 8):

Surgical Expense BenefitDay Surgery MiscellaneousAssistant Surgeon Expense BenefitAnesthetistOutpatient ExpensesMedical EmergencyPhysician’s VisitsX-Rays/LaboratoryTests & ProceduresInjectionsPhysiotherapyChemotherapy and Radiation Therapy

Outpatient Benefits (cont.)Outpatient Expenses Benefit

Students have a $150 Deductible per policy yearInsured Dependents have no deductibleMedical Emergency Room visits have extra $50 deductible per visit

Coverage80% of Usual and Customary or 80% of the actual charge, whichever is less$900 maximum per policy year for Physiotherapy (chiropractic or physical therapy)

Outpatient Expense Benefit - ExampleYou (a student) visit a doctor four times for treatment of mononucleosis. Each visit costs $100 (U&C). In addition, lab tests cost $250. How much does the U of I Student Plan pay?

A) 0

B) 80

C) 400

D) 520

E) None of the above

Outpatient Expense Benefit – Example 2

You fall off a skateboard and skin your knee. You go to the emergency room to have it treated. You are billed $500 for the emergency room visit (U&C). How much does the U of I Student Plan pay?A) 0B) 240C) 280D) 300E) None of the above

Ambulance Expense Benefit

For land ambulance or air ambulance (medical emergency only)

80% of Usual and Customary or

80% of actual charge

Outpatient Diagnostic Procedures

For illness or accidental bodily injury, plan pays 80% of lower of U & C or

80% of actual charge up to:

CT scans $800

MRI 1200

Nuclear Imaging 782

Psychiatric and Drug Abuse Treatment

Inpatient

Same as any other illness (but with $20,000 lifetime maximum)

Outpatient

50% of charge up to maximum of:

$35 per day

45 days per policy year

Psychiatric and Drug Abuse Treatment - Example

You visit a psychiatrist 50 times in one year. Each visit is a different day. Each visit costs $100. How much does the U of I Student Plan pay?

A) 0

B) 1575

C) 1750

D) 2500

E) None of the above