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Definitions

Academic Year means the fall term, spring term

Benefit Period means the policy period from the effective date to the termination date.

Deductible means a specific amount of covered charges that must be incurred by and paid for by the insured person before benefits will be paid.

Doctor as used herein means a legally qualified physician licensed by the state in which he or she practices; a practitioner of the healing arts performing services within the scope of his or her license as specified by the law of the state or residence of such practitioner; or a certified nurse mid-wife while acting within the scope of that certification.

Eligible Expense or Covered Charge means the usual, customary, and reasonable charges or contracted rate or services or supplies, which are incurred by the covered person for the medically necessary treatment of injury or sickness. Eligible expenses must be incurred while the policy is in force and listed as a covered service under the description of benefits. Eligible expenses are subject to all deductibles, coinsurance, and policy maximums as stated in the schedule of benefits.

Hospital means a facility that meets all of the following criteria:

  • It provides inpatient services for the care and treatment of injured and sick people.
  • It provides room and board services and nursing services 24 hours a day.
  • It has established facilities for diagnosis and major surgery.
  • It is supervised by a doctor.
  • It is run as a hospital under the laws of the jurisdiction in which it is located.

Hospital does not include a place run mainly for alcoholics or drug addicts or as a convalescent home, a nursing home, or a hospice facility.

Hospital Confinement means a stay of 18 or more consecutive hours as a resident bed-patient in a hospital.

Injury means bodily injury caused by an accident, which is the sole cause of the loss. All injuries due to the same or a related cause are considered the same injury.

Insured Person means an insured student.

Insured Student means a student of Western Illinois University who is eligible, insured, and assessed the Student Health Insurance fee for coverage under this plan.

Medical Emergency or Emergency Medical means the unexpected onset of an injury or sickness that requires immediate or urgent medical attention, which, if not provided, could be life threatening, result in a loss of life, or result in serious permanent damage to a limb or organ or pain sufficient to warrant immediate care. A medical emergency does not include elective or routine care.

Medically Necessary means a service or supply that is necessary and appropriate for the diagnosis or treatment of an injury or illness based on generally accepted current medical practice. A service or supply will not be considered medically necessary if . . .

  • It is provided only a convenience to the insured person or provider.
  • It is not the appropriate treatment for diagnosis or symptoms.
  • It exceeds (in scope, duration, or intensity) the level of care that is needed to provide safe, adequate, and appropriate diagnosis or treatment. The fact that any particular doctor may prescribe, order, recommend, or approve a service does not, of itself, make the service or supply medically necessary.

Sickness means illness or disease, which is the sole cause of the loss. Illness includes both normal pregnancy and complications of pregnancy. All sicknesses due to the same or a related cause are considered one sickness.

Usual, Customary, and Reasonable Charge (UCR) means the payment amount, as determined in good faith by the company, for services rendered by a professional provider. The company reserves the right of final determination of the amount payable for any service or supply. The following is the basis for determination of UCR:

  • Usual – an amount a professional provider usually charges for a given service.
  • Customary – an amount that falls within the range of charges for a given service billed by most professional providers in the same locality who have similar training and experience.
  • Reasonable – an amount that, in the opinion of the company, would not be considered excessive, in a particular case. If the charge is in excess of the UCR, no payment will be made with respect to the excess, and the excess will not qualify as a covered expense under this policy.

We, Us, Our refers to Western Illinois University Student Health Benefits.

Right of Recovery

If, according to the terms of the plan, we make any payment that should not have been made, including payment made in error, we may recover that incorrect payment, whether or not it was due to our error, from the provider of services or from any other appropriate party.

Reduction of Benefits

This plan is designed to help the student meet the cost of a sickness or injury. Benefits greater than the actual medical expenses are not allowed. All other insurance coverage is used when determining the amount of benefit payable under this plan.

Other valid coverage shall be deemed as coverage provided by any organization subject to the regulations of insurance law or insurance authorities of any state of the United States or any province of Canada; by any hospital or medical service organization; by any group insurance, automobile medical payments insurance, or by coverage provided by a union welfare plan or employer, or by any employee benefit organization. For the purpose of applying the foregoing policy provision with respect to any covered person, any amount of benefit provided for such insured person pursuant to any compulsory statute (including any worker’s compensation or employees liability statute) whether provided by a governmental agency or otherwise shall in all cases be deemed to be other valid coverage, but in no event shall third party liability coverage be included as other valid coverage.

Coordination of Benefits
This Plan is Secondary

The coordination of benefits provision determines which group has primary responsibility for a claim. Benefits of the primary plan are paid for eligible expenses received by the insured person. This plan, the secondary plan, then makes its benefit determination; however, all plans together will not pay more than 100% of eligible expenses.