Accident and Sickness Medical Insurance Program

WISE Foundation®

Claims Administrator
To file a claim or
to confirm benefits or
for approval of surgery or hospitalization:

STARR Insurance 2010
Claims Administrator

Health Special Risk (HSR)
Tel: 1-866-345-0959
Email: StarrClaims@hsri.com
Available Monday through Friday
7:00 AM – 7:00 PM Central Standard Time

Travel Assistance Provider
For 24-hour emergency medical assistance worldwide
Europ Assistance
Tel: 866-690-5111 inside the USA
Tel: 202-659-7776 collect outside the USA

Medical Network Provider
To find local in-network medical care
Beech Street
www.beechstreet.com

ACE Insurance 2009
Claims Administrator

Health Special Risk (HSR)
Tel: 1-866-345-0959
Email: ACEclaims@hsri.com
Available Monday through Friday
7:00 AM – 7:00 PM Central Standard Time

Travel Assistance Provider
For 24-hour emergency medical assistance worldwide
Europ Assistance
Tel: 866-690-5111 inside the USA
Tel: 202-659-7776 collect outside the USA

Medical Network Provider
To find local in-network medical care
Beech Street
www.beechstreet.com

 

ACE Insurance 2006-2008
Claims Processing Center:

ACE American Insurance Company Accident and Health Claims
1 Beaver Valley Road
PO Box 15417
Wilmington, DE 19850

Frequently Asked Questions


1. What is the purpose of this FAQ document?
This document addresses frequently asked questions about the WISE travel medica linsurance program in which you are enrolled. It accompanies the WISE Accident and Sickness Insurance Handbook that describes the travel insurance limits, conditions and terms. Please note that this FAQ document addresses coverage issues in a broad way, and does not contain all of the policy details that govern the insurance. The policy itself is available from WISE Foundation upon request. In the event of a coverage dispute or discrepancy the wording of the policy on file will apply. Benefits are subject to change without notice.

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2. Who are all the parties involved in this insurance program?
The insurance company is either ACE American Insurance Company or STARR Indemnity and Liability Company, depending on your program start date. Both companies contract with service companies in order to assist you with managing the insurance. Your regular contact should be with the claims administrator, HSR, or Health Special Risk. They can explain what is covered under the insurance and help to evaluate plans for your surgery or hospitalization. HSR also handles your claims. If you have a medical emergency, or need help at times that HSR is closed, Europ Assistance can help with medical and logistical issues. If you need help finding a doctor, the Beech Street website provides the information.

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3. What benefits does this plan offer and what are its limits?
The insurance covers travel medical risks, including Medical Expenses and Emergency Medical Evacuation, that occur while you are on the WISE program inside the US. It doesn’t provide any kind of liability insurance or baggage insurance.

The benefits and limits of the WISE travel medical insurance program are:

Medical Expense $100,000
Emergency Medical Evacuation Unlimited
Emergency Dental $500
Accidental Death and Dismemberment Up to $5,000
Permanent Total Disability $10,000
Return of Mortal Remains Unlimited
Emergency Reunion $ 10,000

See the insurance handbook for more detailed explanations of these benefits.

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4. What are “travel medical risks”?
Travel medical risks are emergency health issues that happen while you are in the US. This insurance is meant to address unforeseen medical expenses that cannot wait until you return to your home country. There are exclusions for routine medical care, for pre-existing conditions, and for a variety of medical risks that are generally covered under regular medical insurance. You should read the insurance handbook to become familiar with the risks that are not covered under this insurance. Coverage is available only to participants who are able to actively participate in the WISE program within the US. It includes coverage for your family to join you if you are hospitalized in the U.S. and it provides the additional benefit of travel assistance services not found in regular health insurance. Travel assistance helps with medical emergencies, such as medical evacuation or translation, while you are on the WISE program.

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5. What qualifies as an emergency health issue?
A medical emergency is a condition caused by an accident or an illness with symptoms that are severe enough that someone could reasonably expect serious jeopardy to health unless there is immediate medical attention.

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6. Where does the insurance cover me?
Coverage is valid in the country of your WISE program. Coverage is no longer effective once the WISE program is over, or you have ceased to be an active participant in the WISE program. Once you have returned home, you will need to use another form of health insurance, even if you became ill or injured while you were overseas. Your Home Country is the country for which you hold a passport. If you hold more than one passport, or have permanent legal status in a country other than the one from which your passport was issued, your Home Country is the one you declare in writing to the insurance company.

Your insurance coverage is not valid whenever you travel outside of the U.S. while participating in your program including on vacations to nearby international destinations such as Canada or Mexico, Bahamas, or while traveling to your home country.

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7. When does the coverage begin and end?
Coverage begins on the day indicated on your insurance card and stays in effect until the end date indicated on your card or you cease to be a participant in the program. The insurance does not cover ordinary travel to and from the airport, or to and from the international disembarkation point. However, if you return from your program by Emergency Medical Evacuation, coverage applies for transportation directly to the designated medical facility or to your home. If you are unable or chose not to continue your program as a WISE participant, the insurance coverage will end prior to the end date of the card.

You may purchase additional coverage should you plan to arrive a few days before the beginning of your program or for the 30 day grace period available to you at the successful conclusion of your program.

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8. Does coverage continue if I travel outside of my Home Country after my WISE program is over?
Coverage ends when your WISE program is over, or the date indicated on your insurance card, whichever is earlier, even if you choose to remain in the US, stay at the program location, or do not return directly home.

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9. There are different deductibles. How do they work?
A deductible is the part of the medical expense for which you are responsible when you first seek medical care for an accident or illness. Once you pay the deductible, the claims administrator will pay all eligible expenses for that accident or illness up to the policy limits. If you use a doctor or hospital that is “in-network”, the deductible is $75. If you use a medical provider that is not “in-network”, the deductible is $150. If you have to use an emergency room, the deductible is $150. You might be able to pay a lower deductible of $75 by using an in-network urgent care facility or doctor’s office instead of an emergency room for situations that are not life-threatening.

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10. Do I have to make any co-payments after I have paid the deductible?
No. Once the deductible has been paid and the insurance is in effect, you’re protected up to the policy limits for covered medical expenses arising from that illness or injury, except for any exclusions or limited provisions under the coverage. For example, out-of-network medical expenses are covered only to “reasonable and customary” payment standards for your geographic areas. After the deductible is paid one time for any illness or injury, no more deductibles are required for follow-up care for the same illness or injury. If you need medical care for a new illness or injury, another deductible would be payable for that.

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11. What does “in-network” and “out-of-network” mean?
In-network refers to the doctors, hospitals and other health care providers who have arranged to provide specific medical care to Insureds under this policy at negotiated rates. Out-of-network refers to providers who are not part of this contracted arrangement.

This insurance program allows you to receive care from any doctor or hospital. However, your deductible will be lower whenever you use in-network providers. You should choose in-network providers whenever possible, and go to out-of-network providers only when there is not a suitable in-network option in your area. When an out-of-network provider is used, the insurance company will not pay more than reasonable and customary charges for the geographic area, which may be less than the medical bill presented. You may be held responsible for the difference in cost.

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12. How do I locate a nearby In-Network medical provider?
Your insurance company, The insurance company contracts with Beech Street, a company that maintains a database of in-network medical providers. Your deductible will be lower if you use an in-network medical provider. Beech Street provides details on your health insurance card about how to find out about in-network doctors, hospitals, and medical facilities. The best way for you to search the information is at www.beechstreet.com .

Go to the Beech Street website at the beginning of your program to find listings for an in-network general practice physician and an in-network urgent-care facility in your city or zip code. For specific instructions, see question 18. Keep this information available in your wallet should you need it later.

Beech Street does not handle your claims; if you have a claim go to question 14 for information on how to send it to the claims administrator, HSR.

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13. How does Health Special Risk handle my claims?
Health Special Risk, or HSR, is the claims administrator for the WISE program. They determine if claims are covered and how to process them. You can send your claims to HSR and contact them with claims questions. Doctors and hospitals can also call them to confirm the coverage you have available under the WISE insurance program.

When you need to undergo a medical procedure in a situation that is not life-threatening, HSR can work on your case and coordinate your medical care. If your doctor says that you need to pursue further treatment, give them the contact information for HSR, found in question 14, so that they can advise on how to proceed. Non-emergency surgery or medical procedures must be arranged through HSR during business hours. (If you need help in a medical emergency after hours, Europ Assistance can help you.)

HSR is responsible for making claim reimbursements and payments. HSR works for the insurance company but they are not the insurance company and they do not create the policy terms. They do not provide travel assistance service, and they are not a source of information about doctors in-network.

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14. How do I make a claim under this policy?
Send a completed claim form and original medical bills within 90 days to HSR, the claims administrator. Make sure that you send in itemized bills instead of “balance due” statements. You can get a claim form from HSR or from www.wisefoundation.com. HSR works with your insurance company to process your claim. At your request, and of course subject to coverage, they will either compensate the medical provider directly, or reimburse you if you have already paid the bill.

You should keep copies of the claim documents sent to the insurance company until the claim has been settled.

Send claims to:
Health Special Risk Inc. (HSR)
HSR Plaza II
4100 Medical Parkway
Carrollton, TX 75007

Tel: 1-866-345-0959
Email: either ACEclaims@hsri.com or StarrClaims@hsri.com, depending on your program start date


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15. What is the Claim Questionnaire?
After you report a medical claim you may receive a request for additional information from the claims administrator. They may need to know specific information about the accident or injury in more detail than can be included in the claim form. Please provide the information as fully and as quickly as you can and send it back to the claims administrator by return email. This information will help them to correctly process your claim.

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16. What should I do if I have a medical emergency?
If you have a life-threatening emergency, get to the nearest available form of appropriate medical care, which is generally the local emergency room. You can dial 911 to get an ambulance. Then contact both WISE and Europ Assistance as soon as possible.

Europ Assistance is the travel assistance company that specializes in helping when there are medical emergencies. They are available on a 24-hour basis. They can immediately start to work with your doctors to determine the care and the services you need. Europ Assistance can help with language translation, monitor your case, contact your family, and talk with your physician at home. Do not worry that your case may not be serious enough; there is no penalty for calling Europ Assistance and they can be helpful even in cases of minor emergency.

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17. What is the difference between a hospital emergency room and an urgent care center?
Hospital emergency rooms are designed for serious, life-threatening cases and prioritize these cases for treatment. That is why there can be a long wait for care for less serious cases. Emergency Room treatment can also be very expensive. Use the emergency room if you feel that your medical condition is life-threatening.

Urgent care centers are walk-in medical clinics that have the resources to treat most accidents or illnesses that require immediate attention but are not life-threatening. Care can be delivered quickly and effectively for many kinds of medical cases, and they can be a good alternative if you have no regular doctor. If you have to use an emergency room, your deductible will be $150, while the deductible for using an in-network urgent care center is $75.

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18. Can I see a list of doctors or urgent care centers near me now, before I need one?
Go to www.beechstreet.com and click on “Create a personalized directory”. For question one, “Which kind of plan do you have?”, choose “health benefits”. For question 2, “How do you want to search?” start with a range of 5 miles. Specify at least your city and state. For question 3, “”What type of providers do you want listed?’” specify “primary care” in the top box, or make a more specific selection of medical specialty if applicable. In the box below, scroll all the way down to “urgent/emergent care”. Number 4 asks you to name your directory, and a good name for future reference is “In –network doctors and urgent care”. Hit “Create Directory”

The website will produce a printable list of doctors, hospitals and urgent care centers near you. If you do not get a good range of results, expand the range of miles or indicate a different zip code or major town to which you may be close. You can also make a map of these locations. In order to meet with a listed doctor you will need to call the office listed and make an appointment. In order to use an urgent care facility, you need only walk in. Sometimes you may see both hospital emergency rooms and urgent care centers listed in your directory. Where possible, use an urgent care center for emergencies that are not life-threatening, but if your location doesn’t offer one in good range, use the most appropriate hospital listed for emergency care services.

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19. What should I do if I am hurt at work?
There is an exclusion in the coverage for medical expenses that arise from work. This is because these expenses are meant to be paid by Workers’ Compensation, a kind of insurance that employers are required to maintain. If you are hurt at work, contact the claims administrator, HSR, immediately and let them know. They and your insurer can help to arrange coverage for you from your host site’s Workers’ Compensation insurance.

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20. Will the insurance cover me if I am in a car accident and I’m the driver?
The WISE insurance program will cover you if you are in a car accident, but not if you are the driver. If you wish, you can buy coverage for car accidents where you are the driver from WISE for an additional premium of $5 per month. Contact WISE to arrange for the extra insurance. This additional coverage is not valid for Moped’s, Motorcycles, ATV’s, etc. whether licensed for on road use or not.

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21. I think I am already insured for my medical expenses while on the program. What happens then?
The WISE insurance program is mandatory for all participants, regardless of medical insurance you may have at home. Often insurance in your home country will not cover all expenses incurred outside your Home Country. In particular, many policies do not cover Emergency Medical Evacuation. WISE arranges for this insurance to make sure that you don’t encounter gaps in coverage that might impede your medical care while on the WISE program. This insurance is secondary, which means that if there is primary insurance available to you that can cover your medical expense claim, that insurance must provide payment first, or the insurer may seek reimbursement from the primary insurance company. This applies to primary insurance in effect in your home country or in the US.

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22. What is covered under the Medical Expense benefit?
The medical expense limit is $100,000. “Medical expense” means the cost of covered reasonable and customary medical care received in the U.S., such as doctor’s visits or emergency surgery. Insureds must contact HSR before proceeding with any non-emergency surgery or procedure. Medical Evacuation is a separate benefit. There are important exclusions to the medical expense benefit, such as:

Look for the complete listing of exclusions in your coverage pamphlet.

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23. What must I do if I need to get non-emergency surgery?
There is no restriction on covered surgery that cannot wait until the participant returns to their home country without jeopardizing their health. However, when surgery appears to be of a non-emergency nature, you or your doctor must contact Beech Street to determine how to proceed.

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24. Does the insurance pay for my expenses up-front, or do I need to pay and claim for reimbursement?
In cases of medical emergency, the medical provider should contact Europ Assistance. Europ Assistance can authorize direct payment for covered expenses. If no such arrangement is made, or if the visit does not appear to be covered by the insurance, you may be asked to pay the bill up front and make a claim for reimbursement from HSR, the claims administrator.

You should be prepared to pay for non-emergency expenses and submit a claim to the claims administrator later if necessary.

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25. Who is Europ Assistance US? Do they provide travel assistance outside of Europe?
This is the company that provides travel and medical assistance services during emergencies to WISE participants. They do operate worldwide. Their emergency hotline is available 24 hours a day, 7 days a week. You can call them from inside the US at 1-866- 690-5111, and collect from outside the US at202-659-7776. Calls made from the phone number that starts with 866 are free of charge. “Collect” means that you can tell the telephone operator to ask Europ Assistance to accept the phone charges.

Europ Assistance USA provides the following services:

Medical Assistance including referral to a doctor or medical specialist, medical monitoring when you are hospitalized, emergency medical evacuation to an adequate facility, medically necessary repatriation and return of mortal remains.

Travel Assistance includes arrangements for emergency travel, such as assisting an immediate family member to travel to your bedside in the event of an extended hospital stay

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26. What is the HIPAA consent form?
Before Europ Assistance can talk to any party other than you in the event of a medical emergency, they need to know that you give permission for them to discuss your medical case with your doctors, your insurance company, WISE and your family. You gave permission for this use of your medical information in your WISE application and the HIPAA consent form declares this permission to the other parties in a way that is compliant with the medical privacy law. This is why WISE asks you to complete this form in advance of any medical emergency.

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27. How much co verage is available for Emergency Medical Evacuation and how does it work?
The insurance is unlimited for covered emergency medical evacuations. Emergency Medical Evacuation is used when you become injured or ill and the Physician assisting you recommends that your condition requires an Emergency Medical Evacuation to the nearest medical facility where appropriate medical treatment can be obtained, or to your Home Country. It can include the costs of a nurse or physician to accompany you, either on a commercial airliner, on a special chartered plane, or other means of transportation.

It is important to note that Emergency Medical Evacuation is subject to the terms and conditions of the policy, which means that coverage exclusions apply. If it is possible that you could be medically evacuated for a reason excluded under this policy, you should make special provisions for coverage.

Note that Emergency Medical Evacuation is done only in serious cases, where your life is threatened or where you face a risk of permanent disability. It is used when your health would be threatened by using regular forms of transport.

The decision to medically evacuate, and the determination of whether the evacuation is made to the home country or to a different medical facility, is made based on information from medical professionals working on the case.

The process has to be coordinated by Europ Assistance USA in order to be covered, including medical care, transportation arrangements and travel plans for you or for an immediate family member. Do not arrange a Medical Evacuation on your own, or make any arrangements for your family to visit you on your own. Make sure that both Europ Assistance USA and WISE are involved in helping with any medical evacuation plans.

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28. If I have to go to a hospital, will Europ Assistance give them a payment deposit so that I can be admitted?

Europ Assistance can authorize a hospital admission deposit unless there is clear indication that the situation is not an emergency

You should be prepared to pay for non-emergency expenses and submit a claim to the claims administrator later if necessary.

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29. What should I do if I have to pay medical costs up front and need to make a claim?
If you have a medical bill that was not authorized for direct payment by Europ Assistance, such as a medical bill for non-emergency treatment, you may need to pay the bill yourself and claim the expenses back from the insurance company. You can get a claim form from HSR or from www.wisefoundation.com.

Download the accident and illness claim form. Complete it and attach the original medical bills and back-up information requested. Make a copy for yourself and then send in the form as soon as possible, but no later than 90 days after you incur the expense. Send it to the claims administrator as specified in question 14. Shortly after you submit the claim, you will receive an email from the claims administrator asking for further details on the accident or illness. Answer the questions in that email that and return it as quickly as possible so that your claim can be processed.

For more helpful information on how to complete and use a claim form successfully, see the section on Insurance at www.wisefoundation.com.

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30. What information should I take with me if I need to go to a doctor’s office or urgent care center or hospital?
Carry your insurance card with you at all times, and keep your insurance handbook and a copy of the claim form with you as well. You received your insurance card in the same packet with your DS-2019 form. Carry your personalized directory of local doctors or hospitals, which you can create by following the directions in question 18. When you are in the doctor’s office, request a super-bill or a standard health insurance bill. When in the hospital, request a form UB-92 or its equivalent. If the doctor suggests follow-up procedures or surgery that is not of an emergency nature, this should be arranged through HSR.

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31. Does the insurance cover prescription drug charges?
The insurance covers prescriptions made by a medical professional in connection with a covered accident or illness. The policy does not pay for over-the-counter medications, vitamins, or prescription drugs not prescribed in response to an accident or illness, such as birth control pills, weight loss medication or stop-smoking aids. If you want to make a claim for reimbursement of prescription drug costs, download the claim form from www.wisefoundation.com. T he insurance company requires the date, name of drug, person for whom prescribed, and the charge. This information is often attached to the bag by the pharmacist but may come in other forms. Make sure your pharmacy receipt includes all requested information. Cashier receipts are not accepted.

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32. What is the difference between the Emergency Medical Evacuation benefit and the Medical Repatriation benefit?
When you cannot obtain adequate care for a medical situation in your travel location, your physicians may recommend an emergency medical evacuation to a location where you can get adequate medical care. Medical evacuation occurs when insureds need to go to another location to get adequate care for a medical emergency. The Medical Repatriation benefit applies when you must return to your home country because your injury, illness or follow-up care needs make you unable to properly continue with your WISE program. Medical repatriation can occur even when local medical care is adequate.

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33. How does Medical Repatriation work?
Repatriation can occur when a participant receives covered hospitalization or treatment, but is then unable to continue his or her active participation in a WISE program or requires continuing follow-up treatment. WISE, in conjunction with your doctors, can arrange for the repatriation to your country of residence or country of citizenship, when the gravity of the case requires. If medical professionals determine that you can travel safely, you must follow through with the repatriation. Otherwise you will be held responsible for medical costs incurred in the US as a result of opting not to be medically repatriated.

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34. What is the Return of Mortal Remains benefit ?
Return of Mortal Remains means the transport of bodily remains or ashes to your Hom e Country. The process has to be coordinated by Europ Assistance in order to be covered.

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35. How does the Accidental Death benefit work? What is Dismemberment?
This benefit of $5,000 is paid to a beneficiary if you die as the result of a covered Injury that occurred while traveling. It is also payable in the event of quadriplegia. It does not apply to death resulting from illness. The dismemberment benefit is a percentage of that sum and applies to loss of a part of the body, including vision and hearing, from a covered accident but not from illness. There is also a benefit of $2,500 payable for covered injuries that arise from a felonious assault.

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37. How are benefits paid for permanent disability?
A lump sum of $10,000 is payable if you are permanently and totally disabled because of a covered Injury or Illness beyond any hope of improvement and will be prevented from engaging in any profession.

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38. What is the Emergency Reunion Benefit?
If you suffer a covered injury or sickness while in the US and must be confined to a hospital for at least seven days, the insurer will reimburse the expenses for a Family Member to visit you during your stay in the hospital. The benefit pays up to $1,000 per day for a maximum of ten days. The benefit includes transportation and lodging arrangements made in the most direct and economical way and not exceeding the usual level of charges for similar transportation or lodging locally. Benefits need to be approved in advance through Europ Assistance USA, and travel arrangements made by Europ Assistance USA.

“Family Member” means your parent (including stepparent), parent-in-law, spouse, child (including legally adopted or stepchild), son- or daughter-in-law, sister, brother (including stepbrother or stepsister), brother- or sister-in-law.

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39. I like to play sports. Are sports covered under the insurance?
The policy excludes claims arising from professional athletics, amateur or interscholastic athletics. Claims arising from the following sports are excluded: taking part in mountaineering where ropes or guides are normally used; hang gliding, parachuting, bungee jumping, racing by horse, motor vehicle, or motor cycle, snowmobiling, motor cycle/motor scooter riding, scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), spelunking (caving), or parasailing.

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