Cultural Vistas Standard Lite
2024-2025
FSG21-210426-03TM

Using Your Insurance
If you need to seek medical treatment, please be sure to seek care appropriately
for the condition/situation that you are experiencing, as this will make the billingand payment process much smoother.
Here are some guidelines for choosing appropriate medical care.

You can either visit your Student
Zone or call the 24-Hour assistanceline:

24/7 Call-A-Doc

Student Zone

Your plan includes access to a virtual telemedicine service. If you havea minor or non-urgent medical need, you can use 24/7 Call-A-Doc to
see a doctor or get a prescription from anywhere, at any time using
your phone or computer. The rst 2 visits are free of cost andadditional visits are $35. Please visit our website for more details.

The Student Zone is your one-stop
resource for information, advice andassistance with your insurance plan.

Non-Emergency Care
For immediate care in non-emergency situations, you SHOULD go toa Walk-in Clinic, Urgent Care center or local doctor. Urgent Care andWalk-in Clinics are often the best places to seek medical care as you
can walk right in and they require no appointment.
You SHOULD NOT go to the Emergency Room (ER) for this type ofcare unless it is a real emergency situation!

Emergency CareThe Emergency Room (ER) is designed for medical emergencies. If
you need emergency care for any reason, please get to the nearest
Emergency Room (ER) or call the emergency services (911 in theUSA) for immediate treatment.
PLEASE NOTE – an additional $250 Deductible will apply for each
Emergency Room visit for an illness which does not result in a direct
Hospital admission. Injuries are not subject to the deductible.

ID Card
It is extremely important that you carry your insurance ID card withyou at all times and make sure to show it when you seek treatment.
Your ID card will be emailed to you before you travel and should be
kept with you at all times.

Doctor/Hospital Search
You have the freedom of choice to visit any provider you wish,
however you are strongly encouraged to visit medical providers whoare part of the insurance plan network, especially in the USA. This willallow direct billing and can remove the need for you to pay up front for
medical expenses.
• Inside the USA, you can search for a network provider
online.

fifi• Outside the USA, you can seek treatment from any
provider of your choices, pay up front and then le aclaim for reimbursement.

fiNeed Help?

Student Zone
24-Hour AssistanceSeven Corners is available 24-hours
a day to assist you with yourinsurance needs, including precerti cation, claims, emergency
evacuation and much more.
You can contact Seven Corners at:Toll-free: (800) 690-6295
Direct Dial: + 1 (317) 818 2808
assist@sevencorners.com

Bene t Summary
Plan Bene ts

Coverage

Lifetime Plan Maximum$3,000,000

Medical Maximum$100,000, per Insured Person, per Occurrence

Deductible$100 per Insured Person, per Occurrence

Coinsurance

The plan pays 80% of the rst $5,000, then 100%, up to the MedicalMaximum• 14 days to 79 years

Bene t Period

180 days
MedicalHospital Room & Board

Usual, Reasonable, and Customary to the Medical Maximum

Inpatient Hospital Services

Usual, Reasonable, and Customary to the Medical Maximum

Outpatient Hospital / Clinical Services

Usual, Reasonable, and Customary to the Medical Maximum

Emergency Room Services

Usual, Reasonable, and Customary to the Medical Maximum$250 ER Copay, Waived if Admitted

Physician’s Of ce Visits

Usual, Reasonable, and Customary to the Medical Maximum

Urgent Care Visits

Usual, Reasonable, and Customary to the Medical Maximum

Telehealth Consultations or CareWith 24/7 Call-A-Doc: First 2 Visits Are Free I Additional Visits are $35
Usual, Reasonable, and Customary to the Medical Maximum

Prescription Drugs

Usual, Reasonable, and Customary to the Medical MaximumHome Health Care

Usual, Reasonable, and Customary to the Medical Maximum

Extended Care Facility

Usual, Reasonable, and Customary to the Medical Maximum

Local Ambulance

Ground Ambulance Maximum: $1,000
Air Ambulance Maximum: $10,000
DentalDental - Sudden Relief of Pain
Dental - Accident$200 per Occurrence$2,000 per Occurrence
Emergency Services and Assistance

Emergency Medical Evacuation andRepatriation$50,000 (separate from Medical Maximum)

Emergency Medical Reunion$200 per day, 10-day limit$1,000 maximum

Return of Mortal Remains$25,000

Local Burial or Cremation$5,000

Political Evacuation and Repatriation$5,000 per Occurrence
IncludedTrip Interruption$1,000fi24/7 Travel Assistance Servicesfifififi

Other Coverage and Services

Claims
Inside the USA

Claim Forms

If you sought treatment from an in-network provider, andprovided your insurance ID card at the time of treatment,
they should be able to bill the Seven Corners claims team
directly with no payment up front.

You can download a copy of the claim form from theStudent Zone and submit it with your receipts to:
Email - claims@sevencorners.com (recommended)
Fax: (+1) 317 575 2659

PLEASE NOTE - After seeking treatment, even if you are
not required to pay up front, please complete a claim formand email these documents to the claims email forprocessing.

Seven Corners, Inc.
303 Congressional Blvd.
Carmel, IN 46032

Outside the USA

Claims Update

When outside the USA, please seek treatment from aprovider that is nearest to you, pay for the services upfront
and then submit a claim for reimbursement.

Your claims tracking portal, MyAccount, is available in yourStudent Zone and allows you to view your claims activity
and contact the claims team directly with any questions.

Prescription Medications

You can also email the claims team atclaims@sevencorners.com for an update on any claims thathave been submitted.

You will need to pay for any prescription medication up
front and then submit the Rx information and receipt fromthe pharmacy with your claim to be reimbursed.

Eligibility
You are eligible for coverage on this Plan if you meet the following criteria:
A. You are an Insured Person;
A. You are at least fourteen (14) days old on Your Effective Date;
B. You have applied for coverage and are named on the Plan; andC. The Company has accepted premium for You;
B. You are traveling outside Your Home Country;
A. For all Insured Persons, Your Home Country is where You have Your Primary Residence;
B. and For United States citizens, including those with dual citizenship, Your Home Country also the United States,
regardless of where You have Your Primary Residence;
C. You are not a green card holder traveling within the United States or its territories; andD. You are a member of the Participating Organization or a member’s Spouse or Child.
It is Your responsibility to maintain all records regarding travel history and age and to provide any documents
to the Administrator necessary to verify eligibility requirements.

Except as expressly provided for in the BENEFIT SUMMARY, all Charges, costs, expenses and/or claims incurred by theInsured Person, and any claim for death or dismemberment bene ts, and directly or indirectly relating to or arising or resulting
from or in connection with any of the following acts, omissions, events, conditions, Charges, consequences, claims,Treatment (including diagnoses, consultations, tests, examinations and evaluations related thereto), services and/or supplies
are expressly excluded from coverage under this insurance, and the Company shall provide no bene ts or reimbursements
and shall have no liability or obligation for any coverage thereof or therefor:
L. Extreme Activities Exclusion: You are not covered for
Extreme Activities.
M. Financial Risk Exclusion: You are not covered fornancial guarantee, nancial default, bankruptcy, orinsolvency risks.
N. Home Country Exclusion: You are not covered while inYour Home Country. This exclusion is waived for
Sections 3.4.
O. Illegal Activity Exclusion: You are not covered for Injuryor Illness resulting from the commission of a criminal
offense or any other criminal or illegal activity as de nedby the local governing body.
P. Long-Term Disability Exclusion: You are not covered forlong-term disability.
Q. Loss of Life Exclusion: You are not covered for loss oflife. This exclusion is waived for Section 6.2.
R. Medical Supervision Exclusion: You are not covered forTreatment, services, or supplies that are notadministered by or under the supervision of a Physicianor Surgeon and products that can be purchased
without a Physician’s or Surgeon’s prescription.
S. Medical Tourism Exclusion: You are not covered for
conditions for which travel was undertaken to seek
Treatment.
T. Mental Illness Exclusion: You are not covered for Mental
Illness and Rest Cures. This exclusion is waived forSection 3.6.
U. Military Exclusion: You are not covered while on active
duty in the military, naval, coast guard, or air service ofany country or while on duty as a member of a police
force or unit.
V. No Cost Exclusion: You are not covered for Treatment
paid for or furnished under any other individual,
government, or group policy or Expenses incurred at no
cost to You.
W. Occupational Disease Exclusion: You are not covered
for Occupational Diseases.
X. Pandemic Exclusion: You are not covered for any Illness
incurred in the Host Country or Home Country as aresult of an Epidemic, Pandemic, public healthemergency, or other disease outbreak that may affectYour health, except for charges resulting fromCOVID-19/SARS-CoV-2.
Y. Pre-Existing Conditions Exclusion: You are not covered
for Pre-Existing Condition(s). This exclusion is waived
for Sections 3.5 and 5.1 through 5.4.

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A. Acupuncture Exclusion: You are not covered foracupuncture.
B. Aircraft Pilot or Crew Exclusion: You are not covered forInjury sustained while You are riding as a pilot, student
pilot, operator, or crew member, in or on, boarding oralighting, from any type of aircraft.
C. Airworthy Exclusion: You are not covered for Injury
sustained while You are riding as a passenger in any
aircraft which:I. Does not have a current and valid Airworthy
Certi cate; orII. Not piloted by a person who holds a valid andcurrent certi cate of competency for piloting suchaircraft.
D. Athletics Exclusion: You are not covered for Athletics.
E. Competition Exclusion: You are not covered for Injury
while participating in contests of speed or riding ordriving in any type of competition.
F. Congenital Exclusion: You are not covered forCongenital abnormalities and conditions arising out ofor resulting therefrom.
G. Contributory Negligence Exclusion: You are not coveredfor Injury if the proximate cause of the Injury is due toYour failure to take reasonable care with Your own
safety, including but not limited to following applicablelaws, safety regulations, and/or signed waivers.
H. Cosmetic Exclusion: You are not covered for cosmeticor plastic Surgery including deviated nasal septum orbreast reduction, or modi cations of Your physical bodyintended to improve Your psychological, mental, or
emotional well-being including, but not limited to,gender reassignment Surgery and related Treatment.
I. Dental, Vision, and Hearing Exclusion: You are notcovered for False teeth, dentures, dental appliances,dental Expenses, normal ear or hearing tests, hearing
aids, hearing implants, eye refractions, eyeexaminations for prescribing corrective lenses oreyeglasses unless caused by Accidental Injury,eyeglasses, contact lenses, or eye surgery when the
primary purpose is to correct nearsightedness,farsightedness, or astigmatism. This exclusion is waivedfor Sections 4.1 through 4.2.
J. Durable Medical Equipment Exclusion: You are notcovered for Durable Medical Equipment.
K. Exercise Exclusion: You are not covered for exercise
programs whether prescribed or recommended by a
Physician or therapist.

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Exclusions

or dandruff, skin atrophy, skin tags, or any cosmetic
procedures that are not Medically Necessary.
KK.Sleep Disorder Exclusion: You are not covered for sleep
apnea or other sleep disorders.
LL. Specialty Aircraft Exclusion: You are not covered for
Injury while ying in any aircraft being used for acrobaticor stunt ying, racing, endurance tests, rocketpropelled aircraft, crop dusting or seeding or spraying,re ghting, exploration, pipe or power line inspection,
any form of hunting or herding, professional aerial
photography, banner towing, or any experimental
purpose.
MM.Specialty Care Exclusion: You are not covered for
Custodial Care, Educational or Rehabilitative Care, or
any Treatment in any establishment for the care of theaged.
NN.Substance Exclusion: You are not covered for abuse,misuse, illegal use, overuse, dependency upon, or
being under the in uence of alcohol, drugs, chemicals,
or narcotic agents unless administered under theadvice of a Physician and taken in accordance with theproper dosing as directed by the Physician.
OO.Temporomandibular Joint (TMJ) Exclusion: You are notcovered for Treatment of the Temporomandibular joint.
PP. Terrorist Activity and War Exclusion: You are notcovered for Terrorist Activity or War, Hostilities, and Warlike Operations.
QQ.Therapy Exclusion: You are not covered for vocational,
occupational, sleep, speech, recreational, or music
therapy.
RR.Timely Filing Exclusion: You are not covered for claims
which are not received by the Company or Us within
ninety (90) days of the date of service.
SS.Transplant Exclusion: You are not covered for humanorgan transplants, marrow procedures, or tissuetransplants.
TT. Travel Accommodations Exclusion: You are not coveredfor travel accommodations. This exclusion is waived forSections 5.5.
UU.Usual, Reasonable, and Customary Exclusion: You arenot covered for Treatment which:I. Exceeds Usual, Reasonable, and CustomaryExpenses;
II. Is Investigational, Experimental, or for research
purposes; orIII. Is received in a Hospital emergency room visit that is
not a Medical Emergency.
VV. Weight Reduction Exclusion: You are not covered forweight reduction programs or the surgical Treatment ofobesity including, but not limited to, wiring of the teeth
and all forms of intestinal bypass Surgery.

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PLEASE NOTE: This document is being provided for informational purposes only and does not supersede in any way theterms in the governing documents for your insurance plan. Please visit the Student Zone for a copy of your insurance
certi cate which includes the full plan wording and exclusions.

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Z. Prosthesis Exclusion: You are not covered for
replacement of arti cial limbs, eyes, larynx, and orthoticappliances.
AA.Proximity Exclusion: You are not covered for services,supplies, medications, testing, or Treatment prescribed,performed, or provided by a Relative, Family Member,or a person whom You directly supervise at Your placeof employment.
BB.Quarantine Exclusion: You are not covered for
Expenses associated with Quarantine, isolation, orother con nement outside of a Hospital setting;including without limitation: lodging, meals, or otherincidentals.
CC.Radiation Exclusion: You are not covered for exposure
to non-medical nuclear radiation or radioactive
materials.
DD.Reckless Endangerment Exclusion: You are notcovered for Injury if You unreasonably fail or refuse to
depart a country or location following the date awarning to leave is issued and such failure causes orcontributes to Your Injury. Applicable warnings include
those issued by the United States government, theappropriate authorities of either Your Host Country orYour Home Country, or by a global governing body.
EE. Reproductive Exclusion: You are not covered forPregnancy, childbirth, abortion, or Illness orcomplications resulting from these conditions,miscarriage including that resulting from an Accident,
postpartum care, preventing conception or childbirth,arti cial insemination, infertility, impotency, sexual
dysfunction, circumcision, or sterilization or reversal
thereof.
FF. Restricted Travel Exclusion: You are not covered fortravel after Your Physician has limited or restrictedtravel.
GG.Routine Exclusion: You are not covered for routine andpreventative care, vaccinations, sports or schoolrequired physicals, or other examinations or tests
conducted when there are no objective indications orimpairments in normal health. This exclusion is waived
for Section 3.7.
HH.Self-Harm Exclusion: You are not covered for suicide,attempted suicide, self-destruction, or any attempt
thereof, or any intentionally self-in icted Injury or Illness.
II. Sexually Transmitted Infection (STI) Exclusion: You are
not covered for sexually transmitted infections, sexuallytransmitted diseases, venereal diseases, and conditions
and any consequences thereof.
JJ. Skin Exclusion: You are not covered for acne, Alopecia,
hypertrophic scars, moles/nevus, Psoriasis, seborrhea