Student Accident and

Sickness Insurance Plan

2010-2011
Welcome to Colorado State University! Good health care is essential for your academic success
and the CSU Health Network is here to provide high quality health care, counseling, and
prevention services at our campus facility.
Care at the CSU Health Network
Fee-paying students are entitled to access a variety of outpatient medical and counseling
services at the CSU Health Network. Additional information about these services is
provided on page 1 of this brochure. Students are not required to have health insurance to
access these services.
Student Health Insurance
The Student Accident and Sickness Insurance Plan is mandatory for all international
students and all full fee-paying, resident-instruction graduate students unless they opt out
of this coverage by demonstrating proof of comparable coverage through another plan of
insurance. Additional information on mandatory coverage and the waiver process is available
at http://health.colostate.edu/Insurance/index.cfm.
The Student Accident and Sickness Insurance Plan is available on a voluntary basis to domestic
undergraduate students, Guest students, and to graduate students registered for less than 6
credits. More information on eligibility requirements for voluntary coverage is available on
page 3 of this brochure.
A portion of the cost of the Student Accident and Sickness Insurance Plan is used to cover
on-campus care provided at the CSU Health Network. More information about campus care
provided through the student insurance plan is available on page 2 of this brochure.
The Student Accident and Sickness Insurance Plan also provides extensive benefits for off-
campus medical care.
The CSU Health Network is your primary source for medical care and, as necessary, can
provide referrals to an approved provider in order to obtain additional care off-campus. More
information on off-campus care provided through the student insurance plan is available on
page 4 and 5 of this brochure.
Please take some time to review this brochure and to educate yourself about the benefits
that are available to you under the student health insurance plan. If you have any specific
questions about the plan please contact the CSU Health Network, Student Insurance Office
at (970) 491-5118 or visit the CSU Health Network web site at http://health.colostate.edu/.
Have a healthy and happy year!
Stephen D. Blom, Executive Director
CSU Health Network
Colorado State University

Table Of Contents Page

CSU Health Network...............................................1
Campus Care.............................................................2
Eligibility for Accident and Sickness Insurance.........3
International Students...............................................3
Graduate Students.....................................................3
Schedule of Benefits.............................................. 4-5
Referral Requirement................................................4
Inpatient Notification Requirement..........................4
Purchasing the Insurance..........................................6
Coverage Dates..........................................................6
Schedule of Costs/Coverage Dates............................6
How Do I Find A Provider?.......................................7
How Do I File A Claim?...........................................7
Maternity Testing......................................................7
Exclusions.............................................................. 7-8
Definitions............................................................ 8-9
Travel Assistance Program.........................................9
CSU Health Network
All students registered for six or more credit hours automatically pay the health and the university counseling fee and are eligible
to use CSU Health Network. Part-time students, students of the Division of Continuing Education, Guest Students, Continuous
Registration students and spouses or domestic partners may choose to pay the health fee and university counseling fee on a semester
basis or pay for services as they are received at CSU Health Network. Children of students may pay the health fee on a semester basis
or pay for medical services as they are received at CSU Health Network. Children of students may not utilize the newly integrated
counseling and prevention services at our campus facility.
Emphasizing seamless, comprehensive, and innovative health care services, the professional staff through CSU Health Network
provides high quality health care for our students. The professional medical and mental health staff consists of board certified and
licensed physicians, psychiatrists, psychologists, social workers, nurse practitioners, pharmacists, and professional technicians.
Services encompass a wide range of outpatient care including individual, group, and family counseling, Learning Assistance
Programs/testing, substance abuse prevention/treatment, stress management, sports performance programs and the following:
• Children’s Clinic • Psychiatric Services
• Women’s Clinic • Triage / Urgent Care
• Medical Clinic (including Men’s Health)
Ancillary services include: X-ray, Laboratory, and Pharmacy.
In addition, CSU Health Network provides a number of specialty clinics, such as:
• Allergy/Asthma • Dental
• Optometry • Dermatology
•O rthopedic/Sports Medicine • Physical Therapy
Health Promotion Services are available to help promote and support healthy life-style choices through education and counseling.
Health records of students/dependents are kept completely confidential. Health information is not released to anyone without
written approval.
The CSU Health Network at Colorado State University is fully accredited by the Accreditation Association for Ambulatory Health
Care Inc. (AAAHC).
The CSU Health Network hours are:
Academic Year
Monday – Friday...............7:30 a.m. – 5:00 p.m.
Summer
Monday – Friday...............7:30 a.m. – 4:30 p.m.
The CSU Health Network is located west of Morgan Library and east of the intramural field on the main campus.
All registered students are eligible to use CSU Health Network regardless of insurance status. Students who have health problems are
encouraged to establish a relationship with a health care provider upon arriving on campus and to provide previous medical records.

1
 Campus Care
CSU Health Network staff is pleased to offer the following additional benefits to semester fee paying students enrolled in the
accident and sickness insurance plan. A portion of the amounts outlined in the Schedule of Costs (page 6) are allocated for the
additional benefits shown below.
There are two benefit components under this program: One component for medically necessary services when rendered at CSU
Health Network and another component for prescription drugs dispensed at CSU Health Network. Students should access services
at CSU Health Network first before seeking medical care in the community.

• Physical Therapy • Tests/Procedures

Medical Care Benefit • X-Ray • Surgical Procedures
per School Year $1,500 • Laboratory • Infirmary
(Not including prescription drugs) • Consultations • Braces / Casting
• Intravenous Care • Appliances
Prescription Drug Benefit
$ 500 Now includes birth control
per School Year

Campus Care does not cover:

s 
Charges incurred by your s Orthotics s  reventive or elective/over-the-counter
P
spouse/domestic partner s Administrative fees medications and/or treatment
and/or dependent children* s Charges deemed not s Medical charges incurred by students at
s A llergy/Acne treatment or CSU Health Network are not eligible for
medically necessary
medications s C opies of x-rays/medical benefits under the Schedule of Benefits
s Dental care
records shown on Page 4-5
s Massages s Services not listed above
s Services or supplies not
s Routine eye exams rendered at CSU
Health Network

Students – Medical expenses incurred at CSU Health Network do not require a claim form and the pre-existing condition
limitation is waived. Any ineligible expense not payable under the additional benefits outlined above or by the health fee will be
charged to the student’s University account.
* W hile your Spouse/Domestic Partner and/or Dependent Children may seek treatment at CSU Health Network, they are not
eligible for benefits under Campus Care.

Please contact the Student Insurance Office at (970) 491-5118 with any questions.

2
Eligibility For Accident And Sickness Insurance International Students
International Students: The Board of Governors of Colorado State University
• International Students are required to maintain requires international students to enroll in the student
accident and sickness insurance. Please review accident and sickness insurance plan or to show proof of
International Students section on this page. equivalent or better insurance coverage by providing a copy
of the insurance policy to CSU Health Network.
Domestic Students:
International students and their dependents can show
• Admitted Colorado State University undergraduate proof of equivalent or better insurance coverage by providing
students registered for 1 or more credit hours. a copy of the insurance policy to the Student Insurance
• Admitted Colorado State University graduate Office for review no later than the published enrollment/
students. cancellation date (page 6). The health insurance information
will be reviewed by an appointed committee outside of the
• Colorado State University Continuous Student Insurance Office.
Registration students.
International students without approved equivalent health
• Guest students registered for 6 or more credit insurance will be assessed the cost for the accident and
hours (excluding correspondence and distance sickness insurance plan described in this brochure and the
learning courses). semester health fee (if required). This insurance plan exceeds
• The Division of Continuing Education students the minimum J-1 and F-1 Visa requirements.
registered for 6 or more credit hours (excluding Graduate Students
correspondence and distance learning).
All full-fee paying resident-instruction graduate students will
Eligible students who do enroll in this plan may also be required to enroll in the plan available through CSU or
insure their Spouse/Domestic Partner and/or Dependent to opt out by demonstrating proof of comparable coverage
Children (up to age 19). through another plan of insurance.
Students must actively attend class for at least the first 31 Graduate students who are required to have insurance can
days of each enrollment period for which coverage show proof of equivalent or better insurance coverage by
is purchased. providing a copy of the insurance policy to CSU Health
In order to be eligible for the insurance plan, the student Network for review prior to the published enrollment/
must also pay the semester health fee. cancellation date (page 6). The health insurance information
will be reviewed by an appointed committee outside of the
(Anyone eligible for faculty/administrative professional/state- Student Insurance Office.
classified health insurance is ineligible for coverage under
this policy.) International students and graduate students who are
required to have insurance will be automatically re-enrolled
Spouse/Domestic Partner and/or Dependent Children each semester. Please contact the Student Insurance Office,
are eligible for coverage on the student’s enrollment date. CSU Health Network at (970) 491-5118 with any questions
The enrollment date of Spouse/Domestic Partner and/ or visit the web site listed below.
or Dependent Children can be no later than the published
enrollment/cancellation date and must coincide with Effective And Termination Dates
the semester of the student’s insurance enrollment. New Coverage is effective at 12:01 a.m. on the later of:
dependent children are eligible at the time of birth or
adoption provided intent to insure is made within the first • The policy effective date;
31 days. Please contact the Student Insurance Office at (970) • The first date of the term for which an enrollment
491-5118 for more information and the forms required for form and premium are received by our representative;
enrolling an eligible Domestic Partner. or
The carrier maintains its right to investigate student • The day following the date on which the enrollment
status and attendance records to verify that the eligibility form and premium are received by our representative.
requirements have been met. If the carrier discovers that
the eligibility requirements have not been met, a refund of Insurance is effective until the first day of classes the
premium, less any claims paid will occur. following semester – even if you graduate or leave school.
(Please refer to coverage dates on page 6.)
In order for coverage to be continuous, you must enroll your
Spouse/Domestic Partner and/or Dependent Children in the
fall semester, then re-enroll for the spring/summer term.

Additional information regarding the insurance

requirements, waiver forms and frequently asked questions
can be found in the Insurance section of CSU Health
Network web site – www.health.colostate.edu.

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 24-hour Coverage
Off Campus Care Worldwide
Schedule Of Benefits
By enrolling in the Colorado State University Student Accident and Sickness Insurance Plan you have access to Preferred Provider networks. By selecting
a Preferred Provider you will maximize your savings and reduce out-of-pocket expenses because of the significant savings that can be achieved from
the substantially lower rates these providers have agreed to accept as payment for services. This enhancement to your plan does not require you to use a
Preferred Provider. You may receive care from any licensed provider (benefit eligibility is subject to the plan design, exclusions and limitations as specified
in the policy). Please read the information on page 7 to find out how to locate the Preferred Providers in the Fort Collins area and nationwide.
The payment of any Copays, Deductibles, the balance of any Coinsurance amount, and any medical expenses not covered, are the responsibility of the
Covered Person.
Lifetime Aggregate Plan Maximum: $1,000,000

Policy Year Maximum: $250,000 Per Accident or Sickness

$2,000 (Individual) / $3,000 (Family) Includes Deductible, Copay and Coinsurance
Out of Pocket Maximum: If the amount you pay for covered charges in any one policy year reaches the out-of-pocket maximums shown
above, the Company will then pay 100% of additional covered charges for each covered occurrence up to the
overall benefit maximums shown above.
Deductible: $500 (Individual) per Policy Year / $1000 (Family) per Policy Year
First Health / Summit America Direct
Student Insurance Office,
(Please see www.myfirsthealth.com or www.summitamerica-ins.com or Student Insurance Office,
CSU Health Network:
CSU Health Network)
A written referral is required for treatment outside CSU Health Network as outlined below. Only one referral
per condition is required. Referrals must be renewed each subsequent policy year of coverage for ongoing
conditions.
•R
 eferrals are required for illness related consultations and physical therapy.
*Referral Requirement: •N
 o referrals are required for treatment of an accidental injury/medical emergency.
• The referral requirement is waived for immediate onset of an illness when traveling 25 miles or more outside
the Fort Collins area. (Follow up treatment not rendered at CSU Health Network will require a referral).
• Only one referral per condition per policy year is required. Referrals must be renewed each
subsequent policy year of coverage for ongoing conditions.
Your plan requires notification of any inpatient hospital admission or transfer prior
Inpatient Notification Requirement: to the admission or transfer. Please contact Summit America Insurance Services at
1-877-246-6997 to advise them of an impending hospital admission or transfer.
Out-of-Network
Covered Medical Expenses: In-Network Non-Preferred
(Paid after Deductible, applicable Coinsurance and Copays) Preferred Provider Provider
Inpatient Hospitalization Expense Benefits
Hospital Room and Board Expense Benefit:
80% of Preferred Allowance* 60% of (URC)*
Daily semi-private room rate; general nursing care while hospital confined.
Miscellaneous Hospital Expense Benefits:
Covered Medical Expenses include, but are not limited to: the cost of pre-admission
testing, operating room, laboratory tests, anesthesia, blood products, prescription drugs 80% of Preferred Allowance 60% of (URC)
(excluding take home drugs), x-rays, oxygen, temporary surgical appliances and other
miscellaneous services.
Surgical Expense Benefits
Covered Medical Expenses include, but are not limited to: Inpatient and outpatient
surgery expense, anesthesia expense, assistant surgeon expense, and second 80% of Preferred Allowance 60% of (URC)
surgical opinion.
Outpatient Expense Benefits
Physician’s Office Visit or Consultation Expense Benefit: (*See Referral Requirement) 80% of Preferred Allowance 60% of (URC)
80% of Preferred Allowance 60% of (URC)
Hospital Emergency Room Expense Benefit: (subject to $100 Copay) (subject to $100 Copay)
(Waived if Admitted) (Waived if Admitted)
80% of Preferred Allowance 60% of (URC)
Urgent Care Center Expense Benefit:
(subject to $50 Copay) (subject to $50 Copay)
80% of Preferred Allowance 60% of (URC)
Physical / Occupational / Chiropractic Therapy Expense Benefit:
Up to 12 visits per plan year Up to 12 visits per plan year
Intravenous Therapy Expense Benefit: 80% of Preferred Allowance 60% of (URC)
Laboratory Expense Benefit: 80% of Preferred Allowance 60% of (URC)
X-ray / Imaging Expense Benefit: 80% of Preferred Allowance 60% of (URC)
Durable Medical Equipment Expense Benefit: 80% of Preferred Allowance 60% of (URC)
*See page 6 for definition of
“URC” – Usual, Reasonable and Customary and Preferred Allowance 4
 24-hour Coverage
Off Campus Care Worldwide
Schedule Of Benefits
Out-of-Network
Covered Medical Expenses: In-Network Non-Preferred
(Paid after Deductible, applicable Coinsurance and Copays) Preferred Provider Provider
Prescription Drug Expense Benefit
Policy Year Maximum:
Up to $200 Up to $200
(Only when not available at CSU Health Network or for a Medical Emergency when
(Copays: $10 Generic; (Copays: $10 Generic;
CSU Health Network is closed, or for emergent care when outside a 25 mile radius
$35 Brand Name) $35 Brand Name)
of CSU Health Network.)
Maternity Care Expense Benefit
Benefits paid as any other Sickness
80% of Preferred Allowance 60% of (URC)
(See Maternity Testing on page 7 for additional information.)
Mental Health and Substance Abuse Expense Benefits
Biologically Based Mental Health Conditions:
(i.e. schizophrenia, schizoaffective disorder, bipolar effective disorder, major 80% of Preferred Allowance 60% of (URC)
depressive disorder, specific obsessive-compulsive disorder, and panic disorder.)
80% of Preferred Allowance 60% of (URC) (Benefit is
(Benefit is limited up to a limited up to a maximum
Non-Biologically Based Mental Health Conditions - Inpatient: maximum of 45 days for of 45 days for inpatient
Drug and Alcohol Abuse. – Inpatient: inpatient care or 90 days for care or 90 days for partial
partial hospitalization in any hospitalization in any one 12
one 12 month period). month period).
Non-Biologically Based Mental Health Conditions - Outpatient: 80% of Preferred Allowance 60% of (URC) up to a
up to a maximum of 30 visits maximum of 30 visits per
Drug and Alcohol Abuse – Outpatient: per policy year. policy year.
Additional Benefits
Ambulance Expense Benefit: 80% of Preferred Allowance 60% of (URC)
Dental Expense Benefit:
80% of Preferred Allowance 60% of (URC)
Only for expense due to Injury of sound natural teeth.
Well Woman Expense Benefit:
Covered Medical Expenses include one baseline mammogram for women between
80% of Preferred Allowance 60% of (URC)
the ages of 35 and 40. Women age 40 and older have coverage for one annual
(Not subject to Deductible) (Not subject to Deductible)
mammogram per Policy Year. One routine Pap smear for women age 18 and older
per Policy Year.

Well Man Expense Benefit:

Covered Medical Expenses include one Prostate Cancer Screening per Policy Year for 80% of Preferred Allowance 60% of (URC)
men ages 41 and older who are in high risk categories as determined by the Covered (Not subject to Deductible) (Not subject to Deductible)
Person’s doctor. Men ages 51 and older - one screening per Policy Year.
General Provisions - State Additional Benefits:
The Plan will pay benefits in accordance with any applicable Colorado Insurance
Law(s). The following benefits will be paid on the same basis as any other
conditions: Diabetic Equipment and Self Management Education Program (please
note that insulin, syringes, and testing supplies are covered under the Prescription
Drug portion of the Plan); Child Health Supervision Services; Congenital Defects; 80% of Preferred Allowance 60% of (URC)
Speech Therapy; Dental Hospitalization and General Anesthesia (applies to
insured Dependent Children only); Autism; Cleft Lip/Cleft Palate; Complication
of Pregnancy; Home Health Care; Hospice; Inherited Enzymatic Disorder and
Prosthetic Devices. Please refer to the Master Policy available at the Student
Insurance Office, CSU Health Network for a full description of benefits.
Travel Assistance Program

Global Emergency Assistance Services PRIOR to making any reservations or travel arrangements,
you MUST CONTACT THE SERVICE PROVIDER -
Emergency Evacuation On Call International at 1-866-509-7715 (U.S.) or
1-603-328-1728 (Worldwide)
See page 9 for full description of benefits.
Medically Necessary Repatriation
Combined Maximum up to $50,000

5
Purchasing The Insurance
The insurance plan may be purchased on the Colorado State Domestic students (excluding graduate students that are
University (CSU) registration system web site or in person at required to have insurance, see graduate student section,
the Student Insurance Office during the open enrollment. page 3) who do not wish to purchase the student insurance,
Guest students and the Division of Continuing Education please indicate “No” on the CSU registration system web
students may sign up in the Student Insurance Office prior site. If you have any questions about your decision, please call
to the enrollment/cancellation date: the Student Insurance Office at (970) 491-5118 prior to the
published enrollment / cancellation deadline date.
Enrollment/Cancellation If you withdraw from classes within the enrollment period
Semester Deadline (except for documented and approved medical reasons),
Fall Semester September 8, 2010 your coverage and that of your dependents will terminate
Spring/Summer Semester February 2, 2011 retroactive to the effective date of coverage and a full refund,
less any claims paid will be made. No refund will be given if
Summer (12 Week Session) May 16, 2011 a withdrawal is made after the enrollment period ends and
Summer (8 Week Session) June 13, 2011 the insurance will remain in force.
If you choose to purchase this insurance plan, your student A portion of the costs outlined below are used to cover
account will be billed. No enrollments or cancellations will administration services and Campus Care.
be allowed after the published enrollment/cancellation date.
Insured students may enroll their Spouse / Domestic Partner Schedule Of Costs
and/or Dependent Children (up to age 19) in the Student Student Only Spouse All Children
Insurance Office, only through the published enrollment/
Fall $ 998 $1,971 $ 1,297
cancellation deadline date and only for the semester the
student is enrolling for coverage. A newborn child or a child Spring/Summer $ 1,012 $2,196 $ 1,207
placed with you for adoption shall be covered for 31 days Summer Only $ 597 $1,444 $ 791
from birth or date of placement. During these 31 days we
Coverage Dates For
must receive written notice of the birth or placement and 2010/2011 School Year
receive the required premium for coverage to continue. The
insurance costs will be billed to the student’s University Semester
account. Fall August 23, 2010 – January 17, 2011
You must re-enroll yourself, your Spouse/ Domestic Partner and/ Spring/Summer January 18, 2011 – August 21, 2011
or your Dependent Children each semester to have continuous Summer Only May 16, 2011 – August 21, 2011
coverage. Re-enrollment is not automatic! International students June 13, 2011 – August 21, 2011
please refer to page 3 of this brochure.

6
How Do I Find A Provider? Maternity Testing
When you need health care, please access CSU Health This policy does not cover routine, preventive or screening
Network first for treatment or to obtain a referral to a examinations or testing unless medical necessity is established
Preferred Provider. When referred or in the event of an based on medical records. Certain maternity tests and screening
emergency, benefits will be paid at a higher level if you obtain exams will be considered, if all other policy provisions have
treatment or medical services from a provider in the First been met. These include a pregnancy test if positive, CBC,
Health or Summit America Direct networks. You are strongly Hepatitis B surface antigen, Rubella screen, Syphilis screen,
encouraged to utilize these providers whenever possible as this RBC, Blood typing, Rh Blood Antibody Screen, blood glucose,
can reduce your out-of-pocket expenses. Detailed information and urinalysis. The plan will also consider one basic ultrasound
about network providers is available by visiting per pregnancy. Additional ultrasounds may be covered, however
www.summitamerica-ins.com, www.myfirsthealth.com or by will require establishment of medical necessity through medical
calling (877) 246-6997. records. Fetal Stress/Non-Stress tests are payable when medically
Providers are subject to change. Please contact the provider necessary. Prenatal vitamins are not covered. Maternity benefits
prior to obtaining medical care/treatment in order to confirm are considered as any other sickness and subject to all plan
their participation in the First Health or Summit Direct limitations and exclusions. Most laboratory tests listed above are
networks. available through CSU Health Network. Please refer to page 2,
Campus Care, for an outline of benefits.
How Do I File A Claim?
Exclusions
If you have medical charges that may be considered by the
policy, you must initiate the submission process. No benefits will be paid for loss or expense caused by or
resulting from:
• You can obtain a claim form at CSU Health Network in
the Student Insurance Office or on Summit America’s • Pre-Existing Conditions for the first six-months following a
web site below. covered person’s effective date of coverage under this policy
unless Continuous Coverage is applied.
• Return the completed claim form, along with all of the
medical bills and Explanation of Benefit statements from • Services and supplies to students at CSU Health Network,
your primary insurance carrier (if applicable) to the its employees, Doctors, or other employees of the
address below. Policyholder.

• This information must be received as soon as possible and no • Normal health checkups, preventive testing or treatment,
later than 90 days after the date of accident or onset screening exams or testing in the absence of injury.
of sickness. • Eye examinations, prescriptions or fitting of eyeglasses and
REFERRALS – see page 4 for additional information. contact lenses, or other treatment for visual defects and
problems, unless payable as a covered expense associated
Please submit claims to: with a sickness or injury covered by the policy.
Summit America Insurance Services LC • Hearing examinations or hearing aids, or other treatment
7400 College Blvd., Ste 100 for hearing defects and problems, unless payable as a covered
Overland Park, KS 66210 expense associated with an injury covered by
www.summitamerica-ins.com the policy.
For benefit and claim questions, • Dental treatment (including Temporomandibular Joint –
please call: 1-877-246-6997 TMJ), except as specifically provided for in the Schedule
of Benefits.
Online Services
Please visit our web site at www.summitamerica-ins.com for • War or any act of war, declared or undeclared, or while in
brochures, I.D. cards (printable using Adobe Acrobat), claim the armed forces of any country.
status and other insurance products. • Participation in a riot or civil disorder, commission of or
attempt to commit a felony, or fighting, except
Other Questions? in self-defense.
Please call (970) 491-5118 or stop by the Student Insurance
Office, CSU Health Network. You may also e-mail the office
at: [email protected]
Student Insurance Office Hours
Academic Year
Monday – Friday...............7:30 a.m. – 5:00 p.m.
Summer
Monday – Friday...............7:30 a.m. – 4:30 p.m.

7
(Exclusions continued) Definitions
• Injury of any covered person sustained while: Accident: A sudden, unforeseeable, external event which
a. Participating in any school, professional or organized results in an injury.
sports contest or competition (except intramural), unless Coinsurance: The percentage of Covered Medical Expenses
specifically listed in the Schedule of Benefits; payable by the Covered Person under the Student Health
b. Traveling to or from such sport, contest or competition Insurance Plan.
as a participant; or Continuous Coverage: If a covered person is continuously
c. During participation in any practice or conditioning covered under the policy offered through your participating
program for such sport, contest or competition. institution or comparable health coverage they will be
covered for any sickness diagnosed or injury sustained while
• Skydiving, parachuting, bungi-cord jumping, hang gliding, so covered. If a covered person is enrolled for coverage offered
glider flying, parasailing, sail planing, or flight in any kind through your participating institution within 90 days of the
of aircraft, except while riding as a passenger on a regularly end of any preceding company’s policy you will be considered
scheduled flight of a commercial airline. to have maintained continuous coverage, except for expense
• Treatment in a military or Veterans Hospital or a hospital that are the liability of the previous policy. Coverage cannot
contracted for or operated by a national government or its be considered continuous if a break in enrollment of more
agency unless: than 90 days occurs.
a. The services are rendered on an medical emergency Coordination of Benefits Provision: Benefits under this
basis; and insurance will be coordinated with benefits under other
group insurance that the insured person may have, so that
b. A legal liability exists for the charges made on behalf of a no more than 100% of expenses incurred will be paid by all
covered person for the services given in the absence insurance companies combined.
of insurance.
Copay or Co-payment: The amount that must be paid
• Elective surgery and elective treatment, except as required by the Covered person at the time services are rendered
to correct an injury for which benefits are otherwise by a Preferred Provider. Copayment amounts are the
payable under the policy. This includes but is not limited responsibility of the Covered Person.
to: breast reduction; circumcision; fertility tests; learning
disabilities; non-malignant moles, warts and lesions (except Deductible: A specific amount of Covered Medical
as medically necessary); premarital examinations; sexual Expenses that must be incurred by, and paid for by, the
reassignment surgery; submucous resection and/or other Covered Person before benefits are payable under the
surgical correction for deviated nasal septum (other than Plan. Deductible amounts are the responsibility of the
for necessary treatment of acute sinusitis); tubal ligation; Covered Person.
and weight reduction. Generic Prescription: A Prescription Drug that is not
• A ny loss covered by state or federal worker’s compensation protected by trademark registration, but is produced and sold
law, employers liability law, occupational disease law, or under the chemical formulation name.
similar laws or act. Injury: Injury means bodily harm resulting, directly and
• Replacement braces and appliances. independently of disease or bodily infirmity, from an
accident. All injuries to the same person sustained in one
• A ny accident where the covered person is the operator of accident, including all related conditions and recurring
a motor vehicle and does not possess a current and valid symptoms of injuries will be considered one injury.
motor vehicle operator’s license, except while in a Driver’s
Education Program. Medical Emergency: Acute onset of a condition that is life
threatening and would cause serious damage to the bodily
• Preventive medicines (such as birth control pills, patches function of the patient or a condition that with any delay in
or devices, allergy, acne medicines or routine asthma obtaining medical care, would adversely affect the treatment
medications), serums, vaccines, except for child Health of the condition.
Supervision services.

8
(Definitions continued) Travel Assistance Program
Medically Necessary: Those services or supplies provided Through participation in the Colorado State University
or prescribed by a hospital or doctor: a.) Essential for the student accident and sickness insurance plan, each insured is
symptoms and diagnosis or treatment of the sickness or now eligible for global emergency assistance services through
injury; b.) Provided for the diagnosis, or the direct care and Fairmont Specialty and their service provider, On Call
treatment of the sickness or injury; c.) In accordance with International. Whenever you and your family are traveling
the standards of good medical practice; d.) Not primarily 100 miles or more away from home or in a foreign country,
for your convenience or that of your doctor; and e.) That you can call the toll-free assistance number and access their
is the most appropriate supply or level of service that can international network.
safely be provided. (The fact that a doctor and/or provider Key services include:
may prescribe, order, recommend or approve care, treatment,
services and/or supplies does not, of itself, make such care, Combined Maximum up to $50,000
treatment, services or supplies medically necessary nor Pre-Trip Assistance Services
payable by this insurance policy.)
Passport & Visa Information
Non-Preferred Provider: A health care service or Health Hazards Advisory
supply furnished by a health care provider that is not a
Preferred Provider. Currency Exchange Information
Cultural Information
Pre-Existing Condition: A sickness or injury for which
medical care, treatment, diagnosis or advice was received Weather Information
within the 6 month period prior to the covered person’s Medical Assistance Services:
effective date of coverage. Pregnancy and complications of
Locating Adequate Medical Care
pregnancy shall not be considered a pre-existing condition.
Coordination of Medical Insurance
There is no coverage for a pre-existing condition for the
Prescription Drug Replacement
first 6 months following a covered person’s effective date
of coverage under this policy, unless Continuous Coverage Emergency Transportation Services:
is applied. Emergency Evacuation
The covered person must provide proof of Continuous Medically Necessary Repatriation
Coverage. This is a document from your previous carrier Repatriation of Remains
showing effective and termination dates of coverage.
Visit by a Family Member or Friend
Preferred Allowance: The amount a Preferred Provider will Return of Dependent Children
accept as payment in full for CoveredMedical Expenses.
Emergency Travel Services:
Preferred Brand Prescription Drug: A Prescription Drug
which is protected by trademark registration. Translator and Interpreter Services
Preferred Provider: A provider in the First Health or Lost/Stolen Baggage Assistance
Summit Direct network. Emergency Advance Medical Payment
Right of Subrogation: If claims are incurred as a result of Emergency Message Services
another person’s negligence, the insurance company has the Emergency Cash Advance Assistance
right to seek reimbursement. Emergency Credit Card Replacement
Sickness: Illness or disease diagnosed during the term of Emergency Ticket Replacement
coverage under the Policy for the covered person. Sickness Legal Assistance / Bail
includes pregnancy and complications of pregnancy. All Return of Vehicle Assistance
related conditions and recurring symptoms of sickness will
be considered one sickness. For worldwide emergency medical, legal and travel assistance
information and referral services 24 hours a day, 365 days a
Usual, Reasonable and Customary Charge, Fee or Expense year call:
(URC): The most common charge for similar professional
services, drugs, procedures, devices, supplies or treatment In the U.S., toll free............................1-866-509-7715
within the area in which the charge is incurred, as long as Worldwide, collect............................. 1-603-328-1728
those charges are reasonable. The most common charge
means the lesser of: the actual amount charged by the
provider; the negotiated rate; or the charge which would have
been made by the provider for a comparable service or supply Additional information and brochures are available at the
made by other providers in the same geographic area, as Student Insurance Office, CSU Health Network or call
reasonably determined for the same service or supply. (970) 491-5118.

9
 UNDERWRITTEN BY:
United States Fire Insurance Company
by Fairmont Specialty
a Division of Crum & Forster
Eatontown, NJ 07753

administered by:
Summit America Insurance Services, LC
7400 College Blvd., Ste. 100
Overland Park, KS 66210
Toll Free 1-877-246-6997
Fax 1-913-327-7520
www.summitamerica-ins.com
Hours of Operation: 8:30 a.m. to 5 p.m.
Central Standard Time

CSU Health Network

Fort Collins, CO 80523-8031
www.health.colostate.edu
then “click” on student insurance

Colorado State University is an equal opportunity/affirmative action institution and complies with all Federal and
Colorado State laws, regulations, and executive orders regarding affirmative action requirements in all programs.
The Office of Equal Opportunity is located in 101 Student Services. In order to assist Colorado State University
in meeting its affirmative action responsibilities, ethnic minorities, women, and other protected class members are
encouraged to apply and to so identify themselves.
Please keep this Brochure as a general summary of the insurance. The Master Policy on file at the University
contains all of the provisions, limitations, exclusions and qualifications of your insurance benefits. Any discrepancy
between this brochure and the master policy will be governed by the master policy.

CSUFSG-2011