Parents, Students and School Administrators

Lee County School District

Maximum Benefits/Provisions/Exclusions

EXCESS INSURANCE

The Summary of Insurance summarizes the policy provisions and benefits. This policy will not pay 100% of all incurred medical expenses. Policy limits and exclusions apply. Policy benefits are payable, subject to the limits specified in the Summary of Insurance, for accidental bodily injury resulting from a covered accident (or covered illness if the optional In-Hospital Sickness Benefit Option is purchased). The company will pay the reasonable cost of covered eligible medical charges not to exceed the maximum benefits listed in the policy (summarized in this website). The maximum benefit payable for any one covered accident is $25,000.00; or $30,000.00 if the enhanced plan is purchased . The maximum payable under the optional In-Hospital Sickness Benefit Option is $5,000.00 in the aggregate for all covered in-hospital expenses due to covered illness or disease. First medical treatment by a licensed physician or dentist for a covered condition must be obtained within ninety (90) days from the original date of the covered injury or condition to be eligible for policy benefits. The company will pay for covered medical charges for treatment and care rendered within 52 weeks after the date of a covered accident or condition.

POLICY DEFINITIONS

“Covered Accident” means bodily injury of the insured that results directly and independently of all other causes from a covered accident occurring while the policy is in force. Self-inflicted injuries caused by prolonged over exertion, stress or strain, or disease process or aggravation of an existing condition is expressly excluded from coverage under the accident policy. “Covered Charges” means reasonable charges which are not in excess of usual and customary charges; not in excess of the maximum benefit amount payable for services specified below; services and supplies which are not excluded from coverage; and services and supplies which are a medical necessity for treatment of the covered accident. “Pre-Existing Condition” means any physical condition for which the existence of symptoms would cause a normally prudent person to seek medical care or advice. Physical condition includes any complication or residual of a prior illness, condition or disease the person was advised or treated for in the six (6) months before the effective date of the Insured’s coverage under the policy. “Sickness” means an illness or disease for which symptoms first originate and for which medical treatment is rendered by a physician while this Endorsement is in force. All related conditions and recurrent symptoms of the same or a similar condition will be considered one sickness. “Hospital” means a licensed or properly accredited general hospital which is open at all times and operated primarily and continuously for the treatment of and surgery for sick and injured persons as inpatients under the supervision of one (1) or more legally qualified physicians available at all times with continuous, twenty-four (24) hour nursing services by Registered Nurses on duty or call. “Hospital” does not mean a facility that is primarily a clinic, nursing, rest or convalescent home, or an institution specializing in or primarily treating mental or nervous disorders, alcoholics or drug addicts. “At-School Accident Coverage” applies while a covered person is in attendance at the school during the hours and on the days that school is in session; participating in activities, except as a spectator, which are exclusively school-funded, school-sponsored, school-supervised and scheduled by the school on or away from school premises, during or after school hours or school-sponsored religious instruction; traveling by bus directly and without interruption to or from the covered person’s residence and the school for regular school sessions or such travel time as is required, how-ever, not to exceed one (1) hour before the regular school classes begin and not more than one (1) hour after school is dismissed; while a covered person is participating in a school-scheduled, school-sanctioned interscholastic sports practice or competition at or away from school premises (except grades 9th, 10th, 11th and 12th grade tackle football). “24-Hour Accident Coverage” includes “At-School Coverage” and extends coverage to twenty-four (24) hours per day while a covered person is at home, school or on vacation. Under the 24-hour coverage plan, the same benefits, limitations and exclusions of the “At-School Coverage” plan will apply. No benefits are payable for injuries while practicing for or participating in 9th, 10th, 11th and 12th grade tackle football. Additional policy terms and provisions apply which are stated in the Master Blanket Accident Insurance Policy issued to the school district and on file for your review. “Effects of Other Coverage” means the insurance coverage provided under the policy shall be “EXCESS” to any other collectible insurance or plans, including but not limited to auto P.I.P. and auto medical payments, HMOs or PPOs, subject to limits stated in the policy when total charges for treatment of a covered accident are in excess of $250.00. Third party subrogation rights are reserved. Total payments by all insurance plans, including HMOs or PPOs, shall never exceed the total medical expenses incurred.

INSURANCE MAXIMUM BENEFITS

The following provides a brief overview of benefits for the basic and enhanced student accident insurance plans.The benefits are subject to all policy provisions, terms and exclusions.  Claims must be deemed eligible according to the policy provisions before being processed.  Please read a Summary of Insurance for more complete terms, provisions and exclusions.

Maximum Medical Benefit Payable per Covered Accident-Basic or Enhanced benefits are dependent upon the premium paid.                                   Click Here to Purchase Insurance Now!
$25,000 Basic Benefit
$30,000 Enhanced Benefit
Policy Deductible
$0 Deductible - Basic Benefit
$0 Deductible - Enhanced Benefit
Loss of Life, due to covered accident
$2,000 Basic Benefit
$2,500 Enhanced Benefit
Inpatient Hospital Charges - Daily Semi-Private Room & Board Including all miscellaneous charges including supplies, services, operating room, implantable devices, etc. 
$1,000/day - Basic Benefit
$1,250/day - Enhanced Benefit
While in Intensive Care including all miscellaneous charges including supplies, services, operating room, implantable devices, etc.
$1,500/day Intensive Care - Basic Benefit
$2,000/day Intensive Care - Enhanced Benefit
Outpatient Hospital or Same-Day Surgi-Center Charges (Including all supplies, implantable devices and services) When major surgery is performed requiring general anesthesia
$1,000 Basic Benefit
$2,500 Enhanced Benefit
Emergency Room Charges (Within 72 Hours of covered accident)
$250 Basic Benefit
$750 Enhanced Benefit
Physician’s Non-surgical office or hospital visits, consultations (Includes Physician’s Assistant Fees if no Physician is available for treatment; 8 visits maximum)
$60 initial visit - Basic Benefit
$75 initial visit - Enhanced Benefit
$40 follow ups - Basic Benefit
$50 follow ups - Enhanced Benefit
Physician’s Surgery Fees
Per 2008 FL Work Comp Schedule (Part A) - Basic Benefit
Per 2008 FL Work Comp Schedule (Part A) - Enhanced Benefit
Outpatient Laboratory Tests 
$150 Basic Benefit
$300 Enhanced Benefit
X-Rays, CAT and other Scans (Includes interpretation and reading Fees)
$300 Basic Benefit
$500 Enhanced Benefit
MRI (Includes interpretation and reading Fees)
$600 Basic Benefit
$800 Enhanced Benefit
Outpatient Physical Therapy Treatment Visits (limited to 8 per covered injury) 
$40 per visit - Basic Benefit
$50 per visit - Enhanced Benefit
Emergency Ambulance Service (Air or Ground)
$350 Basic Benefit
$500 Enhanced Benefit
Drug Store Prescription Prescribed by Physician
$200 Basic Benefit
$300 Enhanced Benefit
Dental Services (Total amount payable per injured tooth; includes x-rays and supplies)
$250 per tooth - Basic Benefit
$500 per tooth - Enhanced Benefit
Replacement Eyeglasses or Hearing Aids (If broken during a covered accident requiring medical treatment)
$150 Basic Benefit
$250 Enhanced Benefit
Orthopedic Appliances/Braces/Implantable Devices or Rentals (Payable when physician prescribed for rehab. only)
$300 Basic Benefit
$500 Enhanced Benefit
In-Hospital Sickness Option
$500.00 per night while hospitalized for a covered illness or disease up to $5,000.00. Option must be purchased

EXCLUSIONS - WHAT THE POLICY DOES NOT COVER

1. The practice or play of interscholastic tackle football including travel to or from such practice or play if the student is enrolled in the 9th, 10th, 11th, or 12th grades, unless the player has paid the required extra premium. Participation in any organized sports camps, league practices or competitions that are not exclusively funded, sponsored, scheduled and supervised by the Member school district Board of Education to which the Policy is issued. Participation in organized classes, practices or competitions in boxing, wrestling, self-defense, or martial arts, including but not limited to Karate, Aikido, Tae Kwon Do, Jujitsu, Kung Fu, kickboxing or weapons training unless the organized program is exclusively sponsored, funded, and scheduled by the Member school district Board of Education to which the Policy is issued, and directly supervised by a Member school employee.

2. Damage to other than whole, sound, vital and natural teeth or to existing dental bridges, crowns, restorations or braces; orthodontic procedure and services. Treatment for injury or fracture of tooth caused either by decay, infection or the breakdown of a dental restoration.

3. Pathological fractures, stress fractures, boils, athlete’s foot, impetigo or similar skin infection, rashes, poisonous vegetation reactions,  warts, blisters, calluses, cramps, muscle spasms, allergies or allergic reactions, ingrown nails, appendicitis, hernia of any kind, however caused; infections occurring other than as a result of such injury; detached retina; or psychiatric care.

4. Any form of illness, sickness or disease including but not limited to the following: Perthes’Disease, Osgood-Schlatter’s Disease, Osteomyelitis, Osteochondritis, Osteogenesis Imperfecta,  Slipped Capital Femoral Epiphysis, Thrombophlebitis, Hysterical Reactions, or similar conditions (unless the In-Hospital Sickness Benefit  Option is purchased).

5. Any form of fighting or brawling or criminal or felonious assault or the Insured being engaged in an illegal occupation. Intentionally self-inflicted injury.

6. Services or treatment rendered as a part of the member school service by a hospital, physician, or person employed or retained by the member, or by a person related to the Insured by blood or marriage.

7. Riding in or on, being struck by, being towed by, boarding or alighting from, or operating any motorized or engine-driven vehicle. Eligible medical expenses not collectible from other valid coverage will be payable up to $1,500.00.

8. War or any act of war (raids by air, land or sea shall be deemed act of war), civil disobedience, plots or insurrection.

9. Injuries sustained by the Insured for which benefits are payable under any  Workers’ Compensation or Employer Liability Laws, or while engaging in activity for monetary gain from sources other than the Member.

10. Aviation in any form except while the Insured is riding as a passenger in a licensed airplane provided by an incorporated passenger carrier on a regularly scheduled passenger flight and route.

11. Riding in or on, being struck by, being towed by, boarding or alighting from, or operating any snowmobile, all-terrain vehicle, or two (2) or three (3) wheeled motor vehicle.

12. The use of or while under the influence of drugs unless administered as prescribed by a physician.

13. The existence or aggravation of physical or mental infirmity, condition or disease, whether infectious, congenital, secondary or acquired in origin. Conditions or the aggravation of conditions that originated prior to the Insured’s Effective Date not to exceed $250.00.

14. Expense resulting from participating in activities for which benefits would be payable, in the absence of this insurance, under any high school or association-sponsored catastrophe sports accident policy or trust fund is expressly excluded from coverage.

15. Snow skiing, snow tubing, snowboarding, water skiing, wake boarding, surf boarding, hydro-sliding, jet skiing or using any "personal watercraft" as defined by Florida statutes. Injury as a result of skate boarding.

16. Injury as a result of non-traumatic, repetitive, overuse syndrome in excess of a maximum aggregate policy limit of $250.00.

17. Any expense for which a benefit is not listed.

Additional exclusions for the optional In-Hospital Sickness Benefit: No benefits payable due to pregnancy, child birth, abortion, drug or alcohol intoxication, addiction or treatment expense; mental illness, emotional disorders, or psychiatric care; dental care for any cause including TMJ; any out-patient visit, treatment of service; any pre-existing condition or recurrence thereof; any expense due to accidental bodily injury.

This Policy is “Excess Coverage” which means if you have other insurance, an HMO or PPO that is also in effect, this policy will consider payment of eligible medical expenses after your other insurance has provided their full payments. You must file a claim with your other primary insurance to be eligible to receive benefits from this accident insurance policy. If you do not have other primary insurance, this policy will pay up to the specified limits of selected policy plan. A certificate of insurance summarizes the provisions and benefits of the policy #09-0141-2019 (files form #LRS-8985-0100-FL). Any difference between the policy and the certificate will be settled according to the provisions of the policy.

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