BLANKET STUDENT ACCIDENT AND SICKNESS INSURANCE

Especially Designed for International Students/Scholars Attending the

STATE UNIVERSITY OF NEW YORK

For International Students & Scholars, Practical Training Participants and Faculty Temporarily Residing in the USA. This brochure is a summary of your benefits under the plan of insurance sponsored by your school. It is not a contract of insurance. Your coverage is governed by a policy of student accident and sickness insurance underwritten by HM Life Insurance Company of New York HM-1054-11. As evidence of your coverage under the Policy, a Certificate of Insurance will be issued to you.

2011 2012

INJURY & SICKNESS MEDICAL EXPENSE BENEFIT PLAN SUMMARY

SCHEDULE OF BENEFITS TABLE 1 LIMITS COVERED PERSON MEDICAL EXPENSES Maximum Benefit per Injury or Sicknesses Deductible* $200,000

$50 per Injury or Sickness

*Participants Deductible is reduced to $0 if the initial treatment is received at the Recognized Student Health Center or if they are referred by the Recognized Student Health Center. The deductible will also be waived for emergency hospitalization or medical care when the health center is not available and the student is in severe pain and/or delay in receiving immediate medical care could result in placing the students health in serious jeopardy. Participants on OPT/CPT are subject to a $50 deductible per injury or sickness which cannot be waived.

SCHEDULE OF BENEFITS TABLE 2 MEDICAL EXPENSES INDEMNITY PLAN BENEFITS Physician Office Visits, Inpatient Hospital Services, Hospital and Physician Outpatient Services 100% of Reasonable Expenses after deductible.

SCHEDULE OF BENEFITS TABLE 3 MEDICAL EXPENSE BENEFITS The benefits listed below are subject to Maximums per Injury and Sickness and Deductible. In addition, Table 1 and Table 2 Plan Type Limits (Indemnity). MEDICAL EXPENSE LIMITS COVERED PERSON Maternity Care for a Covered Pregnancy Reasonable Expenses Inpatient treatment of mental and nervous disorders Reasonable Expenses for a maximum period of 60 days per Policy Year.

Outpatient treatment of mental and nervous disorders Reasonable Expenses for a maximum of 40 Visits per Policy Year. Outpatient Crisis Intervention Services related to treatment of mental and nervous disorders Reasonable Expenses for up to 3 psychiatric emergency visits per Policy Year. Each visit will reduce the number of visits available under Outpatient Treatment of mental and nervous disorders. Elective termination of pregnancy Reasonable Expenses up to $500 Maximum per Policy Year Routine nursery care of a newborn child of a covered pregnancy Reasonable Expenses up to $1,500 Maximum per Policy Year Medical treatment arising from participation in intercollegiate or interscholastic sports. Reasonable Expenses up to $1500 Maximum per Policy Year Repairs to sound, natural teeth required due to an Injury 100% of Reasonable Expenses Outpatient prescription drugs 100% of actual charge, subject to $10 co-pay for generic medications and $20 co-pay for brand name medications Vaccinations for MMR (measles, mumps, and rubella) and meningitis vaccine 100% of Reasonable Expenses Medical treatment received in the Home Country (While Insured), if NOT covered by Other Plan 100% of Reasonable Expenses up to $5,000 lifetime maximum, during an incidental trip home, if the participant suffers an Injury or Illness, this Plan shall pay up to $5,000 of Covered Expenses for that Injury or Illness. Treatment for this injury or illness must occur within the Participants Home Country while on the incidental visit.

Other benefits may apply as mandated by the State of New York. Pleases see full Certificate of Insurance for more details.

COVERED GENERAL MEDICAL EXPENSES AND LIMITATIONS: Covered Medical Expenses are limited to the Reasonable Expenses incurred for services, treatments and supplies listed below. All. benefits are per Injury or Sickness unless stated otherwise.

No Medical Treatment Benefit is payable for Reasonable Expenses incurred after the Covered Persons insurance terminates as stated in the Period of Coverage provision. However, if the Covered Person is in a Hospital on the date the insurance terminates, the Insurer will continue to pay the Medical Treatment Benefits until the earlier of the date the Confinement ends or 31 days after the date the insurance terminates. If the Covered Person was insured under a group policy administered by the Administrator immediately prior to the Policy Effective Date, the Insurer will pay the Medical Treatment Benefits for a Covered Injury or a Covered Sickness such that there is no interruption in the Covered Persons insurance. 1. Physician office visits. 2. a. Inpatient Hospital Services b. Hospital and Physician Outpatient Services Inpatient Hospital services and Hospital and Physician Outpatient Services consist of the following: Hospital room and board, including general nursing services; medical and surgical (and anesthesia) treatment; medical services and supplies; Outpatient nursing services provided by an RN, LPN or LVN; local, professional ground ambulance services to and from a local Hospital for Emergency Hospitalization and Emergency Medical Care; xrays;laboratory services; radiation therapy, chemotherapy and hemodialysis ordered by a Physician, prescription medicines; artificial limbs or prosthetic appliances, including those which are functionally necessary; the rental or purchase, at the Insurers option, of durable medical equipment for therapeutic use, including repairs and necessary maintenance of purchased equipment not provided for under a manufacturers warranty or purchase agreement; home health care visits of up to four hours of service provided by a home health care aide or a visit by any other home health care provider. Inpatient hospital services include: (a) the use of operating, recovery and cystoscopic rooms and equipment; (b) the use of intensive care or special care units and equipment to the extent not otherwise provided in the policy; (c) diagnostic and therapeutic items, such as drugs and medications, sera, biologicals and vaccines, intravenous preparations and visualizing dyes for care in the hospital, and administration thereof, but not including those which are not commercially

available for purchase and readily obtainable by the hospital; (d) dressings and plaster casts; and (e) supplies and use of equipment in connection with oxygen, anesthesia, physiotherapy, chemotherapy, electrocardiographs, electroencephalographs, X-ray examinations and radiation therapy, laboratory and pathological examinations, blood products, except when participation in a volunteer blood replacement program is available to the Insured Person. The Insurer will not pay for Hospital room and board charges in excess of the prevailing semiprivate room rate unless the requirements of Medically Necessary treatment dictate accommodations other than a semiprivate room. ADDITIONAL COVERED GENERAL MEDICAL EXPENSES AND LIMITATIONS: These additional Covered Medical Expenses are limited to the Reasonable Expenses incurred for services, treatments and supplies listed below. All benefits are per Injury or Sickness unless stated otherwise. 1. 2. Pregnancy Annual cervical cytology screening for cervical cancer and its precursor states for women age 18 and older Mammography screening, when screening for occult breast cancer is recommended by a Physician Prostate screening tests Child Preventive and Primary Care Services Breast Reconstruction due to Mastectomy Diabetes treatment Chemical abuse and Chemical dependency Pre-hospital Emergency Medical Services

3.

4. 5. 6. 7. 8. 9.

10. Bone Density Testing 11. Second Medical Opinion 12. Chiropractic Care 13. End of Life Care 14. Mental/Nervous Conditions

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT Maximum Benefit Principal Sum up to $10,000

The Insurer will pay the benefit stated below if a Covered Person sustains an Injury in the Country of Assignment resulting in any of the losses stated below within 365 days after the date the Injury is sustained:
Loss Benefit

Loss of life Loss of one hand Loss of one foot Loss of sight in one eye

100% of the Principal Sum 50% of the Principal Sum 50% of the Principal Sum 50% of the Principal Sum

Loss of one hand or loss of one foot means the actual severance through or above the wrist or ankle joints. Loss of the sight of one eye means the entire and irrecoverable loss of sight in that eye. If more than one of the losses stated above is due to the same Accident, the Insurer will pay 100% of the Principal Sum. In no event will the Insurer pay more than the Principal Sum for loss to the Covered Person due to any one Accident. The Principal Sum is stated in Table 1 of the Schedule of Benefits.

MEDICAL EVACUATION, REPATRIATION AND BEDSIDE VISIT BENEFITS PROVIDED BY FrontierMEDEX

Medical evacuation and repatriation expenses for insured student, scholars, and their dependents must be arranged for and approved in advance by FrontierMEDEX. Medical Evacuation If a Covered Person sustains an injury or sickness and adequate medical facilities are not available locally, FrontierMEDEX will arrange and pay for covered emergency evacuation services to the nearest facility capable of providing adequate care. FrontierMEDEX will arrange transportation and related medical services (including medical escort) and medical supplies necessary in connection with the evacuation. Security Evacuation - In the event of an Emergency Security Situation, We will on a best-effort basis arrange for Your evacuation from an international airport or other safe departure point We designate to the nearest safe haven. We will pay for Your evacuation up to and including seven (7) days from the date of evacuation notice given by the recognized government of Your Home Country or Host Country. You will be responsible for the cost and arrangement of ground transportation to the designated international airport or other safe departure point. If evacuation becomes impractical due to hostile or dangerous conditions, We will maintain contact with You and advise You

until evacuation becomes viable or the Emergency Security Situation has passed. Political Evacuation - In the event the officials of Your Home Country issue a written recommendation that You leave Your Host Country for non-medical reasons, or if You are expelled or declared "persona non grata" on the written authority of Your Host Country, We will on a best-effort basis arrange for Your evacuation from an international airport or other safe departure point We designate to the nearest safe haven. We will pay for Your evacuation up to and including seven (7) days from the date of evacuation notice given by the recognized government of Your Home Country or Host Country. You will be responsible for the cost and arrangement of ground transportation to the designated international airport or other safe departure point. Natural Disaster Evacuation - In the event of a Natural Disaster, We will, on a best-effort basis, arrange and pay for Your evacuation from a safe departure point We designate to a safe haven of Our selection. We will pay for Your evacuation up to and including seven (7) days from the date an evacuation alert is issued by FrontierMEDEX. If evacuation becomes impractical due to hostile or dangerous conditions, We will maintain contact with and advise You until evacuation becomes viable or the Natural Disaster has passed. Transportation to Departure Point - As part of a Natural Disaster Evacuation, We will arrange and pay for ground transportation to the designated international airport or other safe departure point. We will also arrange and pay for the cost of services to protect Your safety while assembled or during evacuation if required and as determined by FrontierMEDEX. Transportation After Natural Disaster Evacuation Following a Natural Disaster Evacuation and when safety allows, We will coordinate and pay for one-way economy airfare to return You to either Your Host Country or Your Home Country. Transportation after Security or Political Evacuation Following a Security or Political Evacuation and when safety allows, We will coordinate and pay for one-way economy airfare to return You to either Your Host Country or Your Home Country. Medically Necessary Repatriation After initial treatment and stabilization of an injury or sickness of a Covered Person, and if it is deemed medically necessary, this plan will arrange and pay to transport the individual back to his or her permanent place of residence for further treatment or to recover. This includes arranging for transportation and related medical services and medical supplies necessary.

Repatriation of Remains If a Covered Person dies, this plan will arrange and pay for the return of the participants body to their place of residence in their home country. Covered Services includes expenses for embalming or cremation and a minimally necessary casket or container for transport. If the Covered Person was unattended by a family member, Covered Services includes economy roundtrip airfare for a family member to accompany the Covered Persons remains to the place of residence. Funeral expenses are not a Covered Service. Family Airfare Expense After emergency evacuation by FrontierMEDEX and if a Covered Person is alone and is hospitalized at the evacuation destination for more than three (3) consecutive days, then the Policy will pay for economy round-trip airfare to the evacuation destination for a single person designated by the Covered Person. The Policy will also pay for the visitors hotel and meals. The total benefit payable under the policy for the airfare, hotel and meals is $2,500. FrontierMEDEX ID # Outbound: 30591 Inbound: 30601 FrontierMEDEX 24/7/365 Contact Information: FrontierMEDEX Emergency Response Center Baltimore MD 1.410.453.6330 1.800.527.0218

ADDITIONAL BENEFITS
Upon receipt of your insurance ID card, participants will have access to the hthstudents.com website which offers a wealth of important information via a personalized, password protected web page. Information includes: Access to a domestic and international physician network Individuals can check the status of claims they have submitted to HTH Worldwide by viewing their claims history A pharmaceutical translation guide Security information Medical term and phrase translations in 9 different languages News columns that relay tips on national healthcare systems abroad and healthy travel practices, as well as warnings on health hazards and disease outbreaks around the world. All articles are also archived and can be retrieved using an intelligent key word search. Participants can have email alerts on topics of their choice sent to them automatically via email.

DEFINITIONS
Accident (Accidental) means a sudden, unexpected and unforeseen, identifiable event producing at the time objective symptoms of an Injury. The Accident must occur while the Covered Person is insured under the Policy, unless the Covered Person has been continuously insured as stated in the PreExisting Condition Limitation. Covered Medical Expense means an expense actually incurred by or on behalf of a Covered Person for those services and supplies which are: (1) administered or ordered by a Physician; (2) Medically Necessary to the diagnosis and treatment of an Injury or Sickness; (3) are not excluded by any provision of the Policy; and incurred while the Covered Persons insurance is in force under the Policy, except as stated in the Extension of Benefits provision. A Covered Medical Expense is deemed to be incurred on the date such service or supply which gave rise to the expense or charge was rendered or obtained. Covered Medical Expenses are listed in Table 3 and described in Section 2. Emergency Hospitalization and Emergency Medical Care means hospitalization or medical care that results from a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: (1) placing the health of such person or others in serious jeopardy; (2) serious impairment to such persons bodily functions; (3) serious dysfunction of any bodily organ or part of such person; or (4) serious disfigurement of such person. Injury means bodily injury caused directly by an Accident. It must be independent of all other causes. To be covered, the Injury must first be treated while the Covered Person is insured under the Policy unless the Covered Person has been Continuously Insured as stated in the Pre-Existing Condition Limitation. A Sickness is not an Injury. A bacterial infection that occurs through an Accidental wound or from a medical or surgical treatment of a Sickness is an Injury. Medically Necessary means medical and dental service, treatment or supplies which are: (1) Recommended by the attending Physician; (2) Consistent with generally accepted medical practice for the Injury or Sickness, as determined by the Insurer; (3) Generally considered by Physicians in the United States of America to be appropriate for the Injury or Sickness; and (4) Accepted as safe, effective and reliable by a medical specialty or board recognized by the American Board of Medical Specialties. A medical or dental treatment will not be deemed Medically Necessary if the Insurer determines that any service, supply or treatment used or provided in connection with the Injury or Sickness is Experimental or Investigational in nature,

unless an external appeals agent has determined, upon review, that the treatment for the Covered Person was not Experimental or Investigational. The fact that a Physician may prescribe, order, recommend or approve a service or supply does not, of itself, make the service or supply Medically Necessary. If services do not meet the criteria above or are not consistent with professionally recognized standards of care with respect to quality, frequency or duration, such services will not be deemed Medically Necessary. Reasonable Expense means the normal charge of the provider, incurred by the Covered Person, in the absence of insurance, (1) for a medical service or supply, but not more than the prevailing charge in the area for a like service by a provider with similar training or experience, or (2) for a supply which is identical or substantially equivalent. The final determination of a reasonable and customary charge rests solely with the Insurer. Sickness means an illness, ailment, disease, or physical condition of a Covered Person starting while insured under the Policy, unless the Covered Person has been Continuously Insured as stated in the Pre-Existing Condition Limitation. Pregnancy is considered a sickness.

LIMITATIONS AND EXCLUSIONS

PRE-EXISTING CONDITION LIMITATION
Preexisting conditions are covered for Eligible Participants under this program.

GENERAL POLICY EXCLUSIONS

Unless specifically provided for elsewhere under the Policy, the Policy does not cover loss caused by or resulting from, nor is any premium charged for, any of the following: 1. Plastic or cosmetic surgery, unless they result directly from an Injury which necessitated medical treatment. This exclusion does not apply to a congenital condition or anomaly of an Eligible Participants child insured under the Policy that resulted from a functional defect. 2. Participating in a felony. 3. For treatment, services, supplies, or Confinement in a Hospital owned or operated by a national government or its agencies. (This does not apply to charges the law requires the Covered Person to pay.) 4. Treatment to the teeth, gums, jaw or structures directly supporting the teeth, including surgical extractions of teeth, TMJ dysfunction that is dental in nature or skeletal irregularities of one or both jaws including orthognathia and mandibular retrognathia, unless they result directly from an Injury which

necessitated medical treatment. This exclusion does not apply to treatment due to a congenital condition or anomaly. 5. Loss due to war, declared or undeclared; service in the armed forces of any country or international authority; or riot. 6. Riding in any aircraft, except as a passenger on a regularly scheduled airline or charter flight. 7. Expenses incurred as a result of pregnancy that is not covered. 8. Voluntarily using any drug, narcotic or controlled substance, unless as prescribed by a Physician.

HOW

TO

ENROLL

If you are a student, scholar, visiting faculty member of other individual affiliated with The State University of New York (SUNY), you will be automatically enrolled unless you complete a waiver form. The International Student Office or appropriate office on campus will automatically enroll you, if eligible, by submitting your name on a roster to HTH Worldwide Insurance Services. Premium charges are added to your student account statement. If you are a student, scholar, visiting faculty member or individual affiliated with The State University of New York (SUNY), you can enroll your dependent. Please contact your Campus Administrator at the Office of International Services at your SUNY Campus to obtain the dependent enrollment form. You then must complete the application attached to the dependent brochure and mail it with your payment to: HTH Worldwide Insurance Services Attn: Enrollment Department One Radnor Corporate Center, Suite 100 Radnor, PA 19087 1.866.281.1668

CERTIFICATION COVERAGE

OF

GROUP HEALTH PLAN

If you are no longer eligible to be insured under this plan, you should request a Certificate of Group Health Plan Coverage from HTH Worldwide Insurance Services. This request can be made by phone or in writing. This request must include the name of the school and the name of each person who is no longer eligible to be insured under this plan.

HOW

TO

FILE A CLAIM

Claims are to be submitted to HTH Worldwide, P.O. Box 30259, Tampa, FL, 33630, USA. See the www.hthstudents.com website for claim forms and instructions on how to file a claim.

PREFERRED PROVIDER NETWORK

This policy includes the voluntary utilization of the Aetna Open Choice Nationwide Preferred Provider Network. Utilizing this Network will decrease your out-of-pocket costs under this Accident and Sickness Insurance Plan. Aetna Open Choice consists of hospitals, physicians and other health care providers, which are organized into a network for the purpose of delivering quality health care at a preferred fee. You are not required to utilize an Aetna Open Choice provider. In order to use the services of a participating provider you must present your HTH Identification Card. An insured person may visit hthstudents.com to receive information on providers in their area or may contact HTH Worldwide Customer Service at 1.888.350.2002.

Program Administered by:

HTH Worldwide
One Radnor Corporate Center, Suite 100 Radnor, PA 19087 1.888.350.2002 FAX: 1.610.254.8797 hthstudents.com [email protected] Assistance Services Provided by:

FrontierMEDEX 8501 LaSalle Road, Suite 200 Towson, MD 21286 1.800.527.0218 1.410.453.6330 www.medexassist.com Servicing Broker:

Haylor, Freyer & Coon, Inc. 231 Salina Meadows PO Box 4743 Syracuse, NY 13221-4743 1.800.289.1501 1.315.451.1500 FAX: 1.315.453.1722 www.haylor-college.com/suny Insurance Underwritten by:

HM LIFE INSURANCE COMPANY OF NEW YORK 420 Fifth Avenue, Third Floor, New York, New York, 10018 1.800.328.5433
REV 06/11