School Insurance of Florida

Insuring Florida's kids for over 40 years.

Sunday 26th of September 2021 06:34 AM

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Manatee County School District

Maximum Benefits/Provisions/Exclusions

EXCESS INSURANCE

The Certificate 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 on the summary of insurance, for accidental bodily injury resulting from a covered school related accident (or away from school if the 24 Hour 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 subject to the specified limits of coverage. First medical treatment by a licensed physician or dentist for a covered accident must be obtained within thirty (30) days from the original date of the covered accident 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.

POLICY DEFINITIONS:                                                                PURCHASE INSURANCE NOW!!

“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. “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; traveling directly and without interruption to or from the covered person’s residence and the school for regular school sessions or such travel time not to exceed one (1) hour before the regular school classes begin and not more than one (1) hour after school is dismissed. The policy excludes Interscholastic Sports, Middle School Sports,Cheerleading, ROTC, Band, color guard units unless the mandatory sports activity fee is paid. “24-Hour Accident Coverage” 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 “ Basic At-School Coverage” plan will apply. 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. Third party subrogation rights are reserved. Total payments by all insurance plans, including HMOs or PPOs, shall never exceed the total medical expenses incurred.

SUMMARY OF THE ACCIDENT INSURANCE POLICY BENEFITS AND LIMITATIONS

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The school policy does not guarantee 100% payment of all medical bills. Specific policy limits are summarized as follows:

1) A $50.00 deductible applies to all claims;

2) students are required and must receive medical treatment by a licensed physician within thirty (30) days following the date of a covered school accident to be eligible for policy benefits;

3) If other coverage is available, parents must file a claim with other collectible sources of coverage before being eligible to collect supplemental benefits from the school policy;

4) The policy pays up to $25,000 per covered accident for eligible medical treatment expenses rendered within one year from the date of the original covered school accident subject to the following policy limitations: Policy Deductible: A $50.00 deductible will be subtracted from the total benefits payable from the student insurance policy.

Inpatient Hospital Benefits: For daily Semi-Private Room & Board and all hospital miscellaneous charges, supplies, services, operating room, implantable devices, etc., the policy pays up to $1,200.00 per day.  In Intensive Care, the policy pays up to $1,500.00 per day for all hospital charges.

Outpatient Hospital or Same-Day Surgi-Center Benefits: If outpatient major surgery requiring general anesthesia is performed, the policy pays up to $1,500.00 for all hospital or Surgi-Center billed charges including supplies, services and implantable devices.

Emergency Room Benefits: The policy will pay up to $150.00 for all Emergency Room Charges if rendered within 72 hours from the time of a covered school accident.

Physician’s Non-Surgical Office or Hospital Visits and Consultations: The initial non-surgical doctor visit is payable up to $50.00; Up to $35.00 is paid for necessary non-surgical follow-up visits; Physician Assistant’s or Nurse’s charges for outpatient visits are not covered.

Surgery Fees: Primary Surgeon’s benefits are paid based upon the fee amounts stated in the Florida Work Comp Fee 2008 Schedule up to a maximum surgeon’s fee benefit of $2,000.00 per accident.

Anesthesiology Benefit: policy pays up to 20% of the surgeon's allowable benefit for anesthesiology services.

X-Rays, MRI, CAT, other Scans (including interpretation and reading fees): All X-Rays: up to $200.00; MRI, CAT and other SCANS: up to $300.00 in the aggregate.

Outpatient Physical Therapy Treatment Visits: Limited to 8 visits per covered injury not to exceed $35.00 per treatment visit.

Orthopedic Appliances: (When used for rehabilitation purposes): up to $150.00.

Drug Store Prescriptions (when prescribed by an M.D. for a covered accident): Up to $100.00.

Emergency Ambulance Service: Up to $500.00 (Air or Ground).

Dental Services: pays up to $300.00 in treatment for each injured sound natural tooth.  

POLICY EXCLUSIONS: The Manatee County Schools Student Accident Insurance Policy DOES NOT COVER the following:1. Participation in  middle school sports, high school sports, ROTC, band, color guard, cheerleading unless the required, mandatory participation fee is paid for by the student.  Participation in any organized sports camps;league practices or competitions during the off-season or summer are excluded.  2. Damage to other than whole, sound, vital and natural teeth or to existing dental bridges, crowns, restorations or braces; orthodontic procedures and services.  Treatment for injury or function 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. 5. Any form of fighting or brawling or criminal or felonious assault or the Insured being engaged in an illegal occupation. 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, except that eligible medical expenses not collectible from other valid coverage will be payable up to $2,000.00 in total. 8. Intentionally self-inflicted injury. 9. War or any act of war; (raids by air, land or sea shall be deemed an act of war), civil disobedience, riots or insurrection. 10. Injuries sustained by the Insured for which benefits are paid or received under any Workmen's Compensation or Employer Liability Laws, or while engaging in activity for monetary gain from sources other than the Member. 11. 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. 12. 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. 13. The use of or while under the influence of drugs unless administered as prescribed by a physician. 14. The existence or aggravation of physical or mental infirmity, condition or disease, whether infectious, congenital, secondary or acquired in origin. 15. Conditions or the aggravation of conditions that originated prior to the Insured's Effective Date. 16. 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. 17. Snow skiing, snow tubing, snowboarding, water skiing, wake boarding, surfboarding, hydro sliding, or jet skiing or using any “personal watercraft” as defined by Florida Statutes. 18. Injury as a result of skate boarding. 19. Miscellaneous supplies and medications, except those administered while hospital confined or when treated in the emergency room. 20. 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 Manatee school district Board of Education to which the Policy is issued, and directly supervised by a Manatee school employee. 21. Any expense for which a benefit is not listed.  

This description of insurance is not a contract and summarizes the Policy # 09-0145-2022 provisions, benefits and exclusions. Additional policy provisions and exclusions apply.  Any difference between the policy and this description or website will be settled according to the provision of the Master Policy issued to the School Board. Contact School Insurance of Florida for more information: 800-432-6915.

FLORIDA LAW STATES: Any person who knowingly and with intent to injure, defraud or deceive any insurance company, files a statement of claim or an enrollment form containing any false or incomplete, or misleading information is guilty of a felony of the third degree.

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