Los Angeles Community College
District Intercollegiate
Athletic and On-Campus
Accident Insurance Program
http://www.aetnastudenthealth.com
Policy Number 846522
2012-2013
Mission College
Southwest College
East L.A. College
Trade-Tech College
City College
Valley College
Harbor College
West L.A. College
Pierce College
15.02.369.1
Who is enrolled in the Plan?
All Student Athletes, Student Coaches, Student Managers and Student Trainers1.
Covered Activity
While participating as a member of a Policyholder sponsored and supervised intercollegiate sport
during: (a) practice sessions; or (b) scheduled games and official tournaments. The covered Injuries
are those received as a result of membership and participation in only the following intercollegiate
activities sponsored by the Policyholder: badminton; baseball; basketball; tennis; swimming and
diving; wrestling; cross country; football; soccer; softball; golf; track and field; volleyball, polo, and
water polo.
All registered students, including cheerleaders, and their dependent children1.
Covered Activity
While participating in Policyholder sponsored and supervised activities while on campus premises
including off-season physical conditioning (except intercollegiate sports activities). Coverage for
dependent children of registered students is provided while they are attending the Policyholder’s
on campus day care facility. Coverage is also provided for the cheerleaders while participating in
Policyholder sponsored and supervised activities, including practice sessions, or while cheering
at scheduled games and official tournaments.
Your school also provides the following:
All formally invited guests of the Policyholder Athletic Department2.
Covered Activity
While traveling in team sponsored transportation only directly to or from the Policyholder's campus
and while visiting the Policyholder's campus and facilities at the Policyholder's expense and/or
based on a formal invitation.
Official visitors, student or academic, while on-campus, who have been issued a formal
invitation to be on the Policyholder's campus2.
Covered Activity
While attending on-campus non-athletic related school events. For official academic non-student
visitors, coverage is provided while on campus: (a) to conduct research; (b) to address the faculty
and/or students; or (c) conduct official school business.
1
The Los Angeles Community College District Intercollegiate Athletic and On-Campus Accident
Insurance Program is underwritten by Aetna Life Insurance Company (Aetna) and administered
by Chickering Claims Administrators, Inc.
2
The coverage above is provided by Axis Global Accident and Health. It is not underwritten or
administered by Aetna Life Insurance Company or its affiliates.
Visit http://www.aetnastudenthealth.com to learn more.
Your Benefits at a Glance
Here is a brief description of the Plan benefits.
Benefit Maximum
$25,000 per accident per policy year
Deductible
$100 per accident or injury
Inpatient Hospitalization
Preferred
Non-Preferred
100% of the Negotiated Charge
100% of the Recognized Charge
Outpatient Hospital Services
Preferred
Non-Preferred
100% of the Negotiated Charge
100% of the Recognized Charge
Physician Services (Benefits include, but are not limited to, surgery, anesthesia, physician visits and consultant and
second opinions.)
Preferred
100% of the Negotiated Charge
Non-Preferred
100% of the Recognized Charge
Emergency Room
Preferred
Non-Preferred
100% of the Negotiated Charge
100% of the Recognized Charge
X-ray, MRI and Lab
Preferred
Non-Preferred
100% of the Negotiated Charge
100% of the Recognized Charge
Additional Services (Benefits include, but are not limited to, physical therapy – max of 36 visits per condition,
Registered or licensed Nurse Expenses and Ambulance.)
Preferred
100% of the Negotiated Charge
Non-Preferred
100% of the Recognized Charge
Durable Medical Equipment (Maximum of $4,000 per Injury.)
Preferred
100% of the Negotiated Charge
Non-Preferred
100% of the Recognized Charge
Emergency Sickness
Not Covered
Dental Services ($5000 maximum per Injury.)
Preferred
100% of the Negotiated Charge
Non-Preferred
100% of the Recognized Charge
Student Health Services (Students/Athletes Tetanus Shot reimbursement for covered injuries through the LACCD
Student Health Centers will be accepted.)
Accidental Death and Dismemberment (AD&D) Benefits
These benefits are underwritten by United States Fire Insurance Company (USFIC) and include the following:
Benefits are payable for the Accidental Death and Dismemberment of Covered Persons, up to a maximum of $25,000.
Pre-existing Condition A pre-existing condition is an injury or disease that was present before your first day of
coverage under a group health insurance plan. If you received medical advice, treatment or services for that injury or
disease or if you took prescription drugs or medicines for that injury or disease during the six months prior to your first
day of coverage, that injury or disease will be considered a pre-existing condition.
Limitation Pre-existing conditions are not covered during the first six months that you are covered under this plan.
However, there is an important exception to this general rule if you have been Continuously Insured. For medically
necessary detoxification, expenses incurred by a covered person as a result of a pre-existing condition of alcoholism
and drug addiction will not be considered covered medical expenses unless no charges are incurred or treatment
rendered for detoxification for a period of 6 months while covered under the policy.
This pre-existing limitation does not apply to Covered Persons under age 19.
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Continuously Insured You have been continuously insured if you (i) had “creditable health insurance coverage” (such
as COBRA, HMO, another group or individual policy, Medicare or Medicaid) prior to enrolling in this plan; and (ii) the
creditable coverage ended within 63 days of the date you enrolled under this plan. If both of these tests are met, then
the pre-existing limitation period under this plan will be reduced (and possibly eliminated altogether) by the number of
days of your prior creditable coverage. You will be asked to provide evidence of your prior creditable coverage.
Once a break of more than 63 days in your continuous coverage occurs, the definition of Pre-Existing Conditions
will apply.
Exclusions:
This Plan does not cover nor provide benefits for:
1.
Sickness, disease or illness expenses.
2.
Expense incurred for injury resulting from declared or undeclared war or any act thereof.
Declared or undeclared war does not include acts of terrorism.
3.
Expense incurred as a result of injury due to participation in a riot. “Participation in a riot”
means taking part in a riot in any way; including inciting the riot or conspiring to incite it. It does
not include actions taken in self-defense; so long as they are not taken against persons who
are trying to restore law and order.
4.
Expense incurred as a result of preventive medicines; serums; vaccines or oral contraceptive.
5.
Expense incurred as a result of commission of a felony.
6.
Expense incurred after the date insurance terminates for a covered person except as may be
specifically provided in the Extension of Benefits Provision.
7.
Expense incurred for treatment of mental or nervous disorders.
8.
The repair or replacement of existing artificial limbs; prosthetic appliances, rental of existing
Durable Medical Surgical Equipment, orthopedic braces; or orthotic devices, unless the
purpose of modifying the item is due to injury while participating in a Covered Activity that
has caused further impairment in the underlying bodily condition.
9.
Air travel via an aircraft owned, leased or operated by the Policyholder, or any aircraft owned,
leased or operated by an employee of the Policyholder on behalf of the Policyholder. This does
not apply to aircraft chartered with pilot or crew on a one time charter basis.
10. Air travel while acting or training as a pilot or crew member. This does not apply if a covered
individual temporarily performs pilot or crew functions in a life threatening emergency.
11. Treatment required for condition caused by repetitive motion injuries and not a result
of a Covered Activity including, but not limited to: stress fracture, strain, shin splint,
Osgood-Schlatter Disease, Chondromalacia, tendonitis, bursitis or heat stroke.
12. Those for new or repair or replacement of dentures; bridges, dental implants, dental bands or
braces or other dental appliances, crowns, caps, inlays or onlays, fillings or any other treatment
of the teeth or gums, except for repair or replacement of sound natural teeth damaged or lost
as a result of an injury while participating in a Covered Activity up to the Accidental Dental
Maximum appearing in the Schedule of Sports Accident Benefits.
13. New or replacement hearing aids, or hearing exams, unless an injury, while participating in a
Covered Activity, has caused impairment or further impairment of a covered person’s hearing.
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14. Expenses incurred beyond 52 weeks from the date of the accident.
15. Treatment for injury to the extent benefits are payable under any state no-fault automobile
coverage; first party medical benefits payable under any other mandatory No-fault law.
16. Expenses for treatment of injury to the extent that payment is made; as a judgment or
settlement; by any person deemed responsible for the injury (or their insurers).
17. Expenses incurred for or in connection with procedures, services, or supplies that are, as
determined by Aetna, to be experimental or investigational. A drug, a device, a procedure, or
treatment will be determined to be experimental or investigational (a) if there are insufficient
outcomes data available from controlled clinical trials published in the peer reviewed literature
to substantiate its safety and effectiveness for the disease or injury involved; or (b) if required by
the FDA, approval has not been granted for marketing; or (c) a recognized national medical or
dental society or regulatory agency has determined in writing that it is experimental,
investigational, or for research purposes; or (d) the written protocol or protocols used by the
treating facility, or the protocol or protocols of any other facility studying substantially the same
drug, device, procedure, or treatment, or the written informed consent used by the treating
facility or by another facility studying the same drug, device, procedure, or treatment, states
that it is experimental, investigational, or for research purposes. However, this exclusion will not
apply with respect to services or supplies (other than drugs) received in connection with a
disease if Aetna determines that: (a) The disease can be expected to cause death within one
year in the absence of effective treatment; and (b) The care or treatment is effective for that
disease or shows promise of being effective for that disease as demonstrated by scientific
data. In making this determination, Aetna will take into account the results of a review by a
panel of independent medical professionals. They will be selected by Aetna. This panel will
include professionals who treat the type of disease involved. Also, this exclusion will not apply
with respect to drugs that: (a) Have been granted treatment investigational new drug (IND), or
Group treatment IND status; or (b) Are being studied at the Phase III level in a national clinical
trial sponsored by the National Cancer Institute; or (c) Are recognized for treatment of the
specific type of cancer for which the drug has been prescribed in one of the following reference
compendia: The American Medical Association Drug Evaluations, The American Hospital
Formulary Service Drug Information, The United States Pharmacopeia Drug Information; or
(d) Recommended by review article or editorial comment in a major peer reviewed professional
journal; or (e) If Aetna determines that available; scientific evidence demonstrates that the drug
is effective or shows promise of being effective for the disease.
18. Expenses incurred for blood or blood plasma; except charges by a hospital for the processing
or administration of blood.
19. Expense incurred by a covered person; not a United States citizen; for services performed
within the covered person’s home country; if the covered person’s home country has a
socialized medicine program.
20. Expense for injuries sustained as the result of a motor vehicle accident; to the extent that
benefits are payable under other valid and collectible insurance; whether or not claim is made
for such benefits. The Policy will only pay for those losses; which are not payable under the
automobile medical payment insurance Policy.
21. Expense for the cost of supplies used in the performance of any occupational therapy.
22. Expense for personal hygiene and convenience items; such as air conditioners; humidifiers; hot
tubs; whirlpools; or physical exercise equipment; even if such items are prescribed by a physician.
Visit http://www.aetnastudenthealth.com to learn more.
23. Expenses for incidental surgeries; and standby charges of a physician.
24. Expense incurred for the use of orthotics; unless used exclusively to promote healing.
25. Expense for charges that are not recognized charges; as determined by Aetna; except that this will
not apply if the charge for a service; or supply; does not exceed the recognized charge for that
service or supply; by more than the amount or percentage; specified as the Allowable Variation.
26. Expense for treatment of covered person who specialize in the mental health care field; and
who receive treatment as a part of their training in that field.
27. Expenses for routine physical exams; including expenses in connection with well newborn
care; routine vision exams; routine dental exams; routine hearing exams; immunizations; or
other preventive services and supplies; except to the extent coverage of such exams;
immunizations; services; or supplies is specifically provided in the Policy.
28. Expense incurred for a treatment; service; or supply; which is not medically necessary; as
determined by Aetna; for the diagnosis care or treatment of the injury involved. This applies
even if they are prescribed; recommended; or approved; by the person’s attending physician;
or dentist.
In order for a treatment; service; or supply; to be considered medically necessary; the service
or supply must:
a. be care; or treatment; which is likely to produce a significant positive outcome as; and no
more likely to produce a negative outcome than; any alternative service or supply; both as
to the injury involved; and the person’s overall health condition;
b. be a diagnostic procedure which is indicated by the health status of the person; and be as
likely to result in information that could affect the course of treatment as; and no more likely
to produce a negative outcome than; any alternative service or supply; both as to the injury
involved; and the person’s overall health condition; and
c. as to diagnosis; care; and treatment; be no more costly (taking into account all health
expenses incurred in connection with the treatment; service; or supply); than any alternative
service or supply to meet the above tests.
In determining if a service or supply is appropriate under the circumstances; Aetna will take into
consideration: information relating to the affected person’s health status; reports in peer
reviewed medical literature; reports and guidelines published by nationally recognized health
care organizations that include supporting scientific data; generally recognized professional
standards of safety and effectiveness in the United States for diagnosis; care; or treatment; the
opinion of health professionals in the generally recognized health specialty involved; and any
other relevant information brought to Aetna’s attention.
In no event will the following services or supplies be considered to be medically necessary:
those that do not require the technical skills of a medical; a mental health; or a dental
professional; or those furnished mainly for the personal comfort or convenience of the person;
any person who cares for him or her; or any persons who is part of his or her family; any
healthcare provider; or healthcare facility; or those furnished solely because the person is an
inpatient on any day on which the person’s injury could safely; and adequately; be diagnosed;
or treated; while not confined; or those furnished solely because of the setting; if the service or
supply could safely and adequately be furnished in a physician’s or a dentist’s office; or other
less costly setting.
Visit http://www.aetnastudenthealth.com to learn more.
29. Expense incurred for which no member of the covered person’s immediate family has any legal
obligation for payment.
30. Expense incurred for custodial care. Custodial care means services and supplies furnished to a
person mainly to help him or her in the activities of daily life. This includes room and board and
other institutional care. The person does not have to be disabled. Such services and supplies
are custodial care without regard to:
a. by whom they are prescribed; or
b. by whom they are recommended; or
c. by whom or by which they are performed.
31. Expense incurred for the removal of an organ from a covered person for the purpose of donating
or selling the organ to any person or organization. This limitation does not apply to a donation by
a covered person to a spouse; child; brother; sister; or parent.
32. Expenses incurred for the repair or replacement of existing artificial limbs; orthopedic braces;
or orthodontic devices.
33. Expense incurred for eye refractions; vision therapy; radial keratotomy; eyeglasses; contact
lenses (except when required after cataract surgery); or other vision or hearing aids; or
prescriptions or examinations except as required for repair caused by a covered injury.
34. Expense incurred as a result of an injury sustained while in the service of the Armed Forces of
any country. Upon the covered person entering the Armed Forces of any country; the unearned
pro-rata premium will be refunded to the Policyholder.
35. Expense incurred for treatment provided in a governmental hospital unless there is a legal
obligation to pay such charges in the absence of insurance.
36. Expense incurred for elective treatment or elective surgery except as specifically provided
elsewhere in this Plan and performed while this Plan is in effect.
37. Expenses incurred for pregnancy, childbirth or miscarriage.
38. Expense incurred for the treatment of alcoholism or drug addiction.
39. Expenses incurred for Pre Existing Conditions.
Any exclusion above will not apply to the extent that coverage of the charges is required under any
law that applies to the coverage.
Order of Benefit Determination for this policy: Excess
Visit http://www.aetnastudenthealth.com to learn more.
Where Can I Go for Service?
How do I file a claim?
First Stop, Student Health Services.
When you need care, consider Student Health
Services as your first stop for on-campus injuries
(for athletic injuries see the athletic trainers first).
They can provide many of the services you
need. You also may visit any licensed health care
provider directly for covered services in Aetna’s
Preferred Provider* network (doctors, specialists,
facilities) except that specific Plan restrictions on
certain services may apply. To learn more about
Preferred Providers*, visit
www.aetnastudenthealth.com.
In order to file a claim, the accident or injury must
be reported to a school administrator within 90
days of the accident or injury. The school official
will then submit the authorization form to Aetna
and you can then access any licensed health
care provider directly for covered services in
Aetna’s Preferred Provider* network (doctors,
specialists, facilities) except that specific Plan
restrictions on certain services may apply.
*Providers are independent contractors and are not
agents of Aetna. Provider participation may change
without notice. Aetna does not provide care or
guarantee access to health services.
Visit http://www.aetnastudenthealth.com to learn more.
Your Home Page @ Aetna Navigator®
Who Is Aetna Student Health?
Once you’re a member of the Plan, you have
access to Aetna Navigator, your secure member
website. It’s packed with personalized benefits
and health information. When you register with
Aetna Navigator, you’ll have your own personal
home page to:
Aetna Student HealthSM is the brand name for
products and services provided by these
companies and their applicable affiliated
companies.
• View your most recent claims
• Print a temporary ID card
• See who is covered under your Plan
• Use Cost of Care tool
• View your health history report which
provides your health data in a portable
and easy to read format
• And much more!
Learn More!
Go to www.aetnastudenthealth.com to learn
more or call 1-855-546-5415.
Aetna has a strong knowledge of accident
insurance benefits and an expansive network
of physicians, hospitals, and other health care
providers. We’ve been offering accident and
sports insurance coverage to students like
you for 30 years at colleges and universities
across the country. We work with your school
administrators to give you access to medical
care when you need it.
This material is for information only. Accident insurance
plans contain exclusions, benefit maximums and
limitations. The plan will pay benefits in accordance
with any applicable California insurance law. If any
discrepancy exists between this pamphlet and the
Master Policy/Group Agreement, the Master Policy/
Group Agreement will govern and control the payment
of benefits. Providers are independent contractors and
are not agents of Aetna. Provider participation may
change without notice. Aetna does not provide care
or guarantee access to health services. Information
is believed to be accurate as of the production date;
however, it is subject to change.
CALIFORNIA (CA)
NOTICE: Any person who knowingly presents a false
or fraudulent claim for the payment of a loss is guilty
of a crime and may be subject to fines and
confinement in state prison
© 2012 Aetna, Inc.
15.02.369.1
Visit http://www.aetnastudenthealth.com to learn more.
©2012 Aetna Inc.
Aetna Student Health
c/o Communications Dept.
200 Rivers Edge Dr
Medford, MA 02155