Catastrophic Major Medical Insurance Plan
NY Residents Only

Why You Need Extra Protection

Rising hospital bills.  Expensive medicines.  Specialized equipment. Advances in medical techniques which prolong life but increase the expense of care. Today's staggering costs for hospital and medical care can easily exceed your ability to pay.

You Are Eligible for Up To $1 Million in Benefits

Now you and each family member you insure can be protected by a $1,000,000 Maximum Lifetime Benefit for each insured person. The Catastrophic Major Medical Benefits Plan complements your current basic medical plan and pays 100% of all eligible expenses for covered sicknesses or injuries (after the plan deductible is met), beyond the limits of your basic plan.

How the Plan Works

It's Easy.

If you are a Columbia University alumnus / alumna, under age 70, you are eligible to enroll for coverage.  Your lawful spouse under age 70 and your unmarried dependent children under age 19 (or under 25 if a full-time student) are also eligible.

Your deductible is the greater of all benefits paid by your basic plan(s), or $25,000 or $50,000 as elected by you.  Your deductible can be satisfied within any consecutive 24-month period.  When your deductible is satisfied the plan pays up to 100% of all reasonable and customary covered charges for the duration of the 3-year benefit period.  When the benefit period ends, a new deductible is required.  This plan pays eligible expenses up to $1,000,000 while insured.

Basic plan means a basic medical plan which provides benefits at least as great as the following:  semi-private room and board of $300 per day for 70 days; $25,000 for extra services; a $5,000 surgical schedule; and a lifetime maximum benefit of $1,000,000.

When Insurance Ends

Once insured, you and your spouse may continue coverage regardless of age - up to the maximum $1,000,000 benefit for each insured.  You can never be terminated for medical reasons.

Earlier termination will occur only if premiums are not paid when due, the group policy terminates or, you cease to be a Member of the Policy Holder.

Coverage for dependents will end when your insurance ends, if dependents' insurance ends under the group policy, the person ceases to be a dependent, or premium for the dependent is not paid when due.   Insured dependents of a deceased Member may continue coverage provided they otherwise remain eligible.

Your Benefits Under the Plan Here is a partial list of the benefits you and your dependants are eligible for when insured: If you are not a Medicare Beneficiary, inpatient hospital charges reduce your catastrophic major medical deductible by $2,000 per day regardless of the actual amount charged.  Once your deductible is met, inpatient hospital benefits, per benefit period, are: First 30 days - $75/day Next 100 days - $100/day Thereafter - $150/day If you are eligible for Medicare, your benefits are equal to the reasonable and customary hospital charges for room and board, up to $400 per day; and up to $800 a day for confinement in and Intensive Care Unit after your elected deductible is satisfied. Doctors' fees  for diagnosis, treatment or surgery; anesthesiologists' fees. Treatment by a licensed physical therapist. X-Rays, laboratory tests, radiation treatment, anesthetics, blood and blood plasma and its administration. Artificial limbs and eyes. Surgical dressings, casts, splints, braces, trusses and crutches. Oxygen and rental of  other necessary equipment for its administration. Private care by a registered  or licensed practical nurse, up to $300 per day, $30,000 per Benefit Period. Convalescent home charges for convalescent or custodial care, up to $300, per week, $46,800 while insured. Home health care, up to 100 visits per Benefit Period. Prescription Drugs. Hospice Care including charges for 210 days of confinement per benefit period and charges for 5 visits for bereavement counseling. And more...

Common Disaster Provision

If more than one family member is injured in the same accident, you only have to meet one Deductible Amount. Each such insured family member will then be eligible for 100% of the benefits for the Benefit Period.

30-Day Free Look

You have 30 days to review the Certificate of Insurance.

The insurer guarantees a 100%  refund of your premium if you  are not convinced of the value of this Plan during these 30 days.

Details and Definitions

Benefit Period
A benefit period starts on the day you incur the first charge towards your deductible, and will end the earlier of:

• The date 12 consecutive months have elapsed during which no charge  was incurred for the injury or sickness, or
• The expiration of three years from the date the first charge was incurred, or
• The applicable maximum benefit has been paid.

Re-establishment of a Benefit Period
You start a new Benefit Period if the condition for which you are receiving benefits continues beyond the Benefit Period, and the applicable maximum benefit has not been paid.  The new Benefit Period starts on the day the first eligible charges are incurred after the end of the previous Benefit Period, provided the Deductible has been reached.

Recurrent Sickness Protection
Once the Benefit Period begins, all eligible expenses due to the same recurrent sickness are covered, until you reach the applicable maximum benefit or until the Benefit Period expires.  A new Deductible will need to be satisfied and a new Benefit Period will begin if there are no  eligible expenses incurred for that sickness for 12 consecutive months.

Pre-Existing Conditions
After the effective date of insurance, you are covered immediately. However, pre-existing  conditions are not covered until the insured person has been covered under the group policy  for 12 continuous months.  Any injury or sickness for which an ordinarily prudent person would have sought medical advice, diagnosis, care or treatment within the six months prior to the effective date is a pre-existing condition.  Pregnancy that exists on the effective date is also a pre-existing condition.  Credit will be given for the above waiting periods if a person has been insured under a previous plan and the coverage under the previous plan ended no more than 60 days prior to the effective date of the group policy, as required by law.

Limitations
This plan pays limited benefits in the following cases:

Charges for eye examinations and eyeglasses are covered only if they result from a non-job related accidental injury  or sickness, or to treat a congenital disease or anomaly.  Dental work to repair damage to sound natural teeth is covered only if incurred in the treatment of a non-job related accidental injury, and the expense must be incurred within 12 months of the accident.

Diagnosis and treatment of alcoholism, alcohol abuse and substance abuse or substance dependency, psychiatric, mental, nervous or emotional disorders, ailments or illness are covered as required by New York law.

Ambulance charges for transportation to the nearest hospital equipped to furnish the required treatment are covered to a limit of $2,000 per benefit period.

What is Not Covered?

The Plan pays you for eligible charges incurred while you are insured and which are recommended by a legally qualified physician who is treating the sickness or injury. No benefit is payable for charges in excess of what you are legally obligated to pay.

Eligible medical expenses do not include charges incurred as a result of:

Charges to buy or rent air conditioners, air purifiers, motorized transportation equipment, escalators or elevators in private homes, eye glass frames or lenses, hearing aids, swimming pools or supplies for them, general exercise equipment, charges for a routine physical exam, except charges for preventative mammography and cytologic screening;  for persons who are not covered under a basic plan (as defined by the group policy), the following charges will not be covered:

• hospital charges incurred  during the first 70 days of each confinement;
• the first $10,000 of charges for chemotherapy, radiation therapy, physical therapy or speech therapy that would otherwise be covered;
• the first $50,000 of charges for physician services that would otherwise be covered; and
• the first $2,500 of charges for prescription drugs while not hospitalized that would otherwise be covered.

War or an act of war; Intentionally self inflicted injury; Treatment that would have been given free of charge if the person was not insured; Losses for  which benefits are payable under any Workers' Compensation Law or similar legislation; Routine nursery care for a newborn child; Treatment given by a person's spouse, his or her spouse's father mother, son, daughter, brother or sister or treatment given by a person's employer, or an employee of such employer.

Answers to Your Questions

This brochure is a summary of benefits only and is subject to the terms, conditions, limitations and exclusions of Group Policy No.E-125, 189, Form No. G-19000/19001.  Coverage may vary or may not be available in all states.

The insurance described in this brochure meets the minimum standards for limited benefit health insurance as defined by the New York State Insurance Department.   It does NOT provide basic hospital, basic medical, major medical, nursing home and/or home care, or long term care insurance as defined by the New York State Insurance Department.