DIANins Student Plan

DIANins White

 

GENERAL FEATURES AND SPECIFICATIONS
Network in U.S. First Health Network in U.S
Lifetime Maximum No lifetime Maximum
Maximum annual $500,000
Maximum per Sickness & Accident $150,000
Deductible $100 Per Injury or Sickness/$45 at Student Health Center
Coinsurance 100% of UCR
Emergency Room Deductible $300 per occurrence
Home Country Coverage $500 Per Policy Period
Area of Coverage Worldwide
Pre-Existing Conditions Covered after 180days
INPATIENT AND HOSPITALIZATION BENEFIT
 Room and Board (semi-private room)  $1,000 per day, Up to 30 days maximum
 Intensive Care/Cardiac Care (If medically necessary)  $1,525 per day to 8 days maximum,Payable in lieu of the Hospital Room and Board Expense.
Hospital Miscellaneous Expenses
(Plus pre-admission Testing) while Hospital Confined
$500 per day, Up to 30 days maximum.
($900 max for pre-admin testing)
Inpatient Consultation (Physician or Specialist)
when requested and approved by the attending Physician
$400 maximum per injury/sickness
Surgeon Expense (Inpatient or Outpatient)
Physician’s fees for surgery. Covered medical expenses will be paid
under this Inpatient benefit; or under the Outpatient surgery benefit, but not for both.
$3,000 per Policy Period
Assistant Surgeon or Anesthesiologist 25% of Surgeon’s Benefit payable
Diagnostic X-Ray and Lab Including Hi-Tech Scans
(CT, MRI & PET) (Inpatient &Outpatient)
$500 maximum per injury/sickness
($850 for hi-tech scans)
Ambulance Service $400 per Policy Period
Emergency Room
-Includes the attending Doctor’s charges, X-rays, laboratory procedures,
use of the emergency room and supplies.
-Subject to an additional copay/deductible of $300 per occurrence.
-If a Plan Participant is admitted to the hospital following visit to the emergency room, the additional deductible is waived
80% of UCR – After the deductible has been satisfied
Chemotherapy, Radiotherapy $1,000 per Policy Period
Reconstructive Surgery Covered under Surgeon Expense Benefit
Mental Health (Inpatient) 80%
OUTPATIENT BENEFITS
Maternity
(conception must occur while this coverage is in effect)
$5,000 maximum for normal delivery,
$7,500 for C-section delivery
Therapeutic Services, Physiotherapy $35 per visit, 1 visit/day
12 visits max
Durable Medical Equipment
Must be medical equipment prescribed by a Doctor that
1) is primarily and customarily used to serve a medical purpose;
2) can withstand repeated use; and
3) generally is not useful to a person in the absence of Injury.
No benefits will be paid for rental charges in excess of the purchase price
$1,000 per Policy Period
Prescription Drugs (Outpatient) $100 per Policy Period
Mental Health (Outpatient) Maximum of 40 visits per year,
$5,000 per Policy Period payable at 80%.
Alcohol and Drug Abuse (Inpatient and Outpatient) Same as any other injury/sickness
Emergency Dental Care
Performed by a Physician; and made necessary by Injury to Natural Teeth.
Routine dental care and treatment to the gums are not covered.
$500 per Policy Period
Outpatient or Ambulatory Surgery
In connection with Outpatient day surgery; excluding nonscheduled surgery and surgery performed in a Hospital emergency room, trauma center, Physician’s office, or clinic.
Benefits will be paid for services and supplies such as: the cost of the operating
room, laboratory tests and X-ray examinations including professional fees,
anesthesia, drugs or medicines, therapeutic services and supplies.
$1,000 per Policy Period
Outpatient Physician Visit
Benefits are limited to one Physician’s visit per day. Benefits do not apply when
related to surgery. Covered medical expenses will be paid under the Inpatient
benefit or under the Outpatient benefit for Physician’s Visits but not both.
$50 per visit, 1 visit per day
30 visits max
Diabetic Supplies
Includes Insulin Pumps and associated supplies
Covered under Prescription Drugs Benefit
ADDITIONAL BENEFITS
Emergency Medical Evacuation and Repatriation $60,000 per Policy Period
Return of Mortal Remains $50,000 per Policy Period
Accidental Death and Dismemberment $10,000 Maximum Benefit
ATM Safe:
Provides lost cash replacement for losses occurring during a robbery at an ATM.
$500 per Occurrence
Travel benefits: Lost baggage Expense reimbursement due to flight delays. $100 per Item
$500 per Policy Period ($100 Deductible)
DIAN White offers international students an alternative to more expensive university plans; it provides health insurance which meets health insurance waiver requirements of most higher education institutions. Coverage is available to all International Students studying outside their home country who are enrolled and actively attending an accredited high school, college or university. The plan offers worldwide coverage, with no geographic restrictions.

Highlights Include:

  • Unlimited Lifetime Maximum
  • Annual Maximum-$500,000
  • Emergency Inpatient and Outpatient Care; Preventative care is covered as well.
  • Worldwide direct-bill network plan, including the Coventry/First Health Preferred Provider network in the US, available with the White plan; there is no need to pay for your health services at the time of delivery
  • The Coventry/First Health Network serves more than 2 million people across the country, with access to more than 5,000 hospitals, over 90,000 ancillary facilities and over 1 million health care professional service locations in all 50 states and the District of Columbia.
  • On-line & live multilingual customer service available 24/7
  • On-line claims filing with www.gbg.com
  • Plans are offered by and administered (claims payment) through Global Benefits Group, Inc., a US based company
Ages ranges Rates in each Period
  Yearly     Monthly    Daily    
12-24 $346 $28.8 $0.95
25-29 $550 $45.8 $1.51
30-40 $1,067 $88.9 $2.93
Dependent $2,260 $188.37 $6.21

Exclusions and Limitations

All services and benefits described below are excluded from coverage or limited under your policy of Insurance.

 

  1. Charges in excess of Usual, Reasonable and Customary allowable charges for any covered procedure
  2. Expenses incurred in your country of Residence over the allowed amount as shown on the Schedule of Benefits
  3. Any incurred expenses after medical repatriation has been offered by the company and turned down by the insured Person
  4. Non-Emergency treatment that is not pre-authorized according to the policy terms and conditions
  5. Charges and Services where claims are not received within 180 days of the date of service
  6. Maternity related treatment or complications for the mother or newborn during the 10-month waiting period
  7. Claims and costs for medical treatment, occurring before the effective date of coverage (including waiting periods) or after the expiration date of the policy. Claims and costs for medical services with dates of service after the policy termination date that are related to accidents, sicknesses, or maternity originating during the policy year, unless the policy has been renewed. This includes any portion of a covered prescription to be used after the expiration of the current policy year
  8. Services, supplies, or treatment including drugs and/or emergency services that are provided by or payment is available from; (a) Workers’ Compensation law, Occupational Disease law or similar law concerning job related conditions of any country, (b) the Insured Person, a family member or any enterprise owned partially or completely by the aforementioned persons, (c) another insurance company or government, (d) under the direction of public authorities related to epidemics
  9. Services, supplies or treatments, including drugs, that are not scientifically or medically recognized for a specific diagnosis, or that is considered as off label use, experimental or not approved for general use are considered experimental or investigational and therefore not eligible services
  10. Any services, supplies, treatments including drugs and/or emergency air services; (a) not ordered by a Physician, (b) not medically necessary, not recommended or approved by a physician, (c) not rendered under the scope of the Physician’s licensing, (d) medical and dental services that do not meet professionally recognized standards or are determined by Insurer to be unnecessary for proper treatment
  11. Telephonic consultations, missed appointments, or “after hours” expenses
  12. Personal comfort and convenience items including but not limited to television, housekeeping services, telephone charges, take home supplies, ambulance services (other than those provided by this Policy), and all other services and supplies that are not medically necessary including expenses related to travel and hotel costs incurred for medical or dental care
  13. Health check-ups, inoculations, visits, and tests necessary for administrative purposes (e.g., determining insurability, employment, school or sport related physical examinations, travel etc.)
  14. Immunizations, other than provided for under the Preventive Care benefit as listed on the schedule
  15. Over-the-counter (OTC) drugs, supplies or medical devices, which do not require a Physician prescription, even if recommended by a Physician, including but not limited to; smoking cessation drugs, appetite suppressant, hair regenerative drugs or products, anti-photo aging drugs, cosmetic and beauty aids, acne and rosacea drugs (including hormones and retin A) for cosmetic purposes;, Megavitamins, vitamins,(other than pre-natal as described under Maternity), sexual enhancement devices, supplements, herbs or drugs, for any reason
  16. Services and supplies related to visual therapy, Radial keratotomy procedures, Lasik, or eye surgery to correct refractive error or deficiencies, including myopia or presbyopia
  17. Rest cures, custodial care, home-like care, assistance with activities of daily living (ADL), milieu therapy for rest and/or observation; whether or not prescribed by a Physician. Any admission to a nursing home, home for the aged, long term care or rehabilitation facility, sanatorium, spa, hydro clinic or similar facilities that do not meet the policy definition of a hospital. Any admission, arranged wholly or partly for domestic reasons, where the hospital effectively becomes or could be treated as the Insured’s home or permanent abode
  18. Elective and or cosmetic surgery, procedures, treatments, technologies, drugs, devices, items and supplies that are not medically necessary treatment of a covered accidental injury or illness or disease, and that may only be provided for the purpose of improving, altering, enhancing, or beautification unless required due to the treatment of an injury, deformity, or illness that compromises functionality and that first occurred while the insured was covered under this policy. This also includes any surgical treatment for nasal or septal deformity that was not induced by trauma. Cosmetic surgery is defined as surgery or therapy performed to improve or alter appearance for self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance
  19. Any medical complications arising directly or indirectly as a result of a non-authorized elective or cosmetic procedure
  20. Medical expenses resulting from a motor vehicle accident in excess of that which is payable under any other valid and collectible insurance
  21. Sleep studies and other treatments relating to sleep apnea including restless leg syndrome
  22. Weight related treatment; any expense, service or treatment for obesity, weight control, or any form of food supplement. This includes expenses related to or associated with treatment of morbid or non-morbid obesity, including, but not limited to, gastric bypass, gastric balloons, gastric stapling, jejunal ileal bypass, and any other procedures or complications arising there from
  23. Organ transplant and related procedures except as specified in the Transplant Services section of this Policy, including but not limited to; (a) donor search expense is excluded, (b) supportive services are not automatically covered and must be approved and managed by GBG Assist, (c) all expenses of cryopreservation and the implantation of living cells on a deceased person or in conjunction with infertility or reproductive treatments, (d) medically necessary organ, blood or cell transplants may be covered on a case by case basis when pre-authorized and managed by GBG Assist
  24. Any fertility/infertility services, tests, treatments and/or procedures of any kind, including, but not limited to, fertility/infertility drugs, including drugs to regulate the menstrual cycle/ovulation for family planning purposes, artificial inseminations, in-vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), surrogate mother and all other procedures and services related to fertility and infertility. Any pregnancy resulting from such treatments, pre-natal care, complications of that pregnancy, delivery and postpartum care are also excluded. Genetic counseling, screening, testing or treatment
  25. Genetic counseling, screening, testing or treatment
  26. Elective abortions; any voluntarily induced termination of pregnancy, unless the mother’s life is in imminent danger
  27. Conditions related to Sex or Gender issues and Sexually Transmitted Diseases. Any expense for gender reassignment, sexual dysfunction including but not limited to impotence, inadequacies, disorders related to sexually transmitted human papillomavirus (HPV). And any other sexually transmitted diseases
  28. Maternity/Delivery Preparation Classes
  29. Circumcisions, unless medically necessary and preauthorized
  30. Treatment of any injury arising directly or indirectly from alcohol or drug abuse or addiction. This includes but is not limited to treatment for any injuries caused by, contributed to or resulting from the Insured’s use of alcohol, illegal drugs, or any drugs or medicines that are not taken in the dosage or for the purposed prescribed by the Insured’s Doctor
  31. Treatment for any conditions as a result of self-inflicted illnesses or injuries, suicide or attempted suicide, while sane or insane, or emergency air services for the same
  32. Injuries and/or illnesses resulting or arising from or occurring during the commission or perpetration of a violation of law by an Insured Person
  33. Eyeglasses; contact lenses; sunglasses
  34. Prosthesis and corrective devices which are not medically required intra-operatively or equivalent appliances; except prosthesis or durable medical equipment used as an integral part of treatment prescribed by a physician, meeting the covered categories of durable medical equipment or prosthesis and approved in advance by GBG Assist
  35. Durable Medical Equipment does not include: motor driven wheelchairs or bed; additional wheels; comfort items such as telephone arms and over bed tables; items used to alter air quality or temperature such as air conditioners, humidifiers, dehumidifiers, and purifiers (air cleaners); disposable supplies; exercycles, sun or heat lamps, heating pads, bidets, toilet seats, bathtub seats, sauna baths, elevators, whirlpool baths, exercise equipment; and similar items or the cost of instructions for the use and care of any durable medical devices. The customizing of any vehicle, bathroom facility, or residential facility is also excluded
  36. Routine podiatry or other foot treatment not resulting from an illness or injury. Orthopedic shoes or other supportive devices for the feet, such as, but not limited to, arch supports and orthotic devices or any other preventative services and supplies; any devices resulting from the diagnosis of weak, strained, unstable or flat feet or fallen arches; or any tarsalgaia, metatarsalgia; or specified lesions of the feet, such as corns, calluses, and hyperkeratosis, toenails or bunions. Pedicures, special shoes and inserts of any form or type
  37. Growth Hormones, unless medically necessary and preauthorized by GBG Assist. This includes treatment by a bone growth stimulator, bone growth stimulation or treatment related to growth hormone, regardless of the reason for prescription
  38. Health care services associated with conditions as a result of travel, following the receipt of advice against travel because of health reasons from any health care provider
  39. Hearing Aids, Hearing Devices and Bone Anchored Hearing Aids
  40. Exceptional Risks; (a) treatment as a consequence of injury sustained while participating in or training for professional sports; (b) treatment as a consequence of injury sustained while participating in, or training for, or as a consequence of: war (declared or not), acts of terrorism , acts of foreign enemy hostilities, civil war, rebellion, revolution or insurrection; (c) .chemical contamination; (d) contamination by radioactivity from any nuclear material or from the combustion of nuclear fuel (e) treatment for any loss or expense of nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with self-exposure to peril or bodily injury, except in an endeavor to save human life
  41. Hazardous Activities includes any activity that exposes the participant to any foreseeable danger or risk. Examples of hazardous activities include but are not limited to aviation sports, rafting or canoeing involving white water rapids in excess of grade 5, tests of velocity, scuba diving at a depth of more than thirty metres, bungee jumping, and participation in any extreme sport
  42. Treatment of Acquired Immune Deficiency Syndrome (AIDS), AIDS-related Complex Syndrome (ARCS) and all diseases caused by and/or related to the HIV Virus, if diagnosed as a pre-existing condition. If diagnosed after the effective date of the Policy and it is proven to be caused by a blood transfusion or accident, a 24 month waiting period applies
  43. Except for accidental injury to sound, natural teeth, dental Care is excluded from coverage; treatment, services or supplies related to (a) the teeth; and (b) the gums other than tumors; and (c) any other associated structures; (d) the prevention or correction of teeth irregularities and malocclusion of jaws by wire appliances, braces, or other mechanical aids; and (e) dental implants, regardless of cause
  44. Treatment services or supplies as the result of prognathism, retrognathism, microtrognathism, or any treatment, services, or supplies to reposition the maxilla (upper jaw), mandible (lower jaw), or both maxilla and mandible. This includes treatment for (TMJD) or Temporomandibular Malocclusion Joint Disorders
  45. This Policy will not cover any services received by any parties or in any countries where otherwise prohibited by the US/UN/EU law and sanctions
  46. Benefits for enrolling solely for the purpose of obtaining medical treatment, while on a waitlist for a specific treatment, or while traveling against the advice of a Physician
  47. Coverage is excluded for treatment and services related to infectious diseases declared to be an outbreak, epidemic, or public emergency by the World Health Organization(WHO), Center for Disease Control and Prevention (CDC), or any other Government or Government Agency or ruling body of the country where the outbreak or epidemic has occurred in. Additionally, such coverage is also excluded if there has been an official warning issued against travel to the area, by the State Department, Embassy, Airline or other Governmental Agency, prior to travel to the affected country. This exclusion will not apply if exposure occurs accidentally or unknowingly while travelling to or from areas not declared to be at risk, or if exposure occurs as a result of residing or working in the area prior to the outbreak

          Accidental Death and Dismemberment Exclusions:

  1. Any loss caused directly or indirectly from extortion, kidnap & ransom or wrongful detention of the Insured or hijacking of any aircraft, motor vehicle, train or waterborne vessel on which the Insured is traveling
  2. Any loss caused directly or indirectly from extortion, kidnap & ransom or wrongful detention of the Insured or hijacking of any aircraft, motor vehicle, train or waterborne vessel on which the Insured is traveling
  3. Any loss whose principal cause sickness or illness.