Interscholastic Sports Accident Plan
Colonna Insurance Services, LLC
1828 Dixwell Avenue
P.O. Box 4245
Hamden, CT 06514
Toll Free: (888) 234-9910
Notice to parents
Your school board has purchased, at no cost to you, an Accident Medical Insurance Plan to help cover medical expenses resulting from interscholastic sport injuries.
All players, coaches, and managers of every interscholastic sport (including cheerleading) are covered throughout the entire school year. The program covers accidental bodily injuries occurring to a covere4d person while participating in or traveling, while under the supervision of proper school authority, to or from any regularly scheduled game or practice of an interscholastic sport.
The Plan your school has purchased may have a $100 Deductible. Please check with your school or the Program Administrator listed on the front of this brochure.
Accidental Death, Dismemberment or Loss of Sight Benefit - When injuries result in any of the losses below within 365 days of a covered accident, the Program will pay:
For Loss of:
- Life - $5,000
- Both Feet or Both Hands or the ENtire SIght of Both Eyes - $20,000
- One Hand and One Foot, One Hand and Entire Sight of One Eye, or One Foot and Entire Sight of One Eye - $20,000
- Thumb and Index Finger of One Hand - $5,000
- One Hand or One Foot or Entire Sight of One Eye - $10,000
If the Insured Person suffers more than one of the above losses as a result of any one accident, only the largest benefit will be paid in addition to any other benefits for medical expense.
Excess Accidental Medical Expense Benefit - When injuries, commencing within 90 days of a covered accident require medical or surgical treatment or (with respect to injury or loss of sound and natural teeth) dental treatment, the Program will pay the amount by which the expenses incurred for the items listed below, within 104 weeks of the accident, exceed the amount(s) payable or service available under automobile medical insurance or any other medical insurance policy or plan. The policy pays the usual and customary charge for the service, supply or treatment given. Benefits shown are per covered accident.
Note: This Plan applies only to that part of the covered expense which is not covered by other applicable insurance or medical service plan.
The Program covers:
- Medical Treatment by a physician or practitioner,* as herein defined, for an injury not requiring surgery or other medical treatment as defined below, not to exceed the usual and customary charges for such visits in the area rendered, up to a maximum of 10 visits per accident.
- Consultants, Specialists, and Second Opinion Fees when requested by the attending physician - pays the usual and customary charge for such services.
- Surgery - pays the usual and customary charge in the area for the surgery performed. The surgical charge is deemed to include pre- and post-operative care. Payment for anesthetists shall not exceed 33 1/3%* (*varies by plan selected) of the allowance for surgery. Under surgery, the maximum payment for multiple procedures performed within the same operative field shall be limited to 150% of the amount payable for the primary procedure.
- Hospital ** Care and Service - When the Insured is confined as a resident patient for at least 24 hours - pays the usual and customary charge for a semi-private room, and ancillary expenses including radiology incurred in the treatment while hospital confined.
- Other Hospital Expense - If the Insured is not confined as a resident patient for at least 24 hours, the Company will pay the usual and customary charge in the area for Emergency Room and Outpatient care.
- Intensive Care when the Insured is confined to a hospital Intensive Care Unit as required by the attending physician - pays the usual and customary charge durching such confinement.
- Radiology when not hospital confined - pays the usual and customary charge in the area. Radiology includes, but is not limited to X-Rays, Magnetic Resonance Imaging, and Computerized Axial Tomography.
- Nurse Service upon recommendation of the attending physician - pays the usual and customary charge for services provided by a registered graduate private duty nurse (R.N.), not related to the Insured, during a period of hospital confinement.
- Emergency Ambulance Service - pays the usual and customary charge for emergency ambulance service from the place of accident to a hospital.
- Dental Treatment - usual and customary charge for accidental injury to one or more sound and natural teeth.
- Drugs and Medications administered in a doctor's office or by prescription (including hypodermic needles or syringes) not to exceed the usual and customary charge.
- Eyeglasses - pays the usual and customary charge for replacement of broken eyeglasses, broken frames or broken lenses resulting from a covered accident. This benefit is payable only in conjunction iwth an injury requiring medical or surgical treatment. Routine refractions or routine eye examinations are not covered under the Policy.
- Orthopedic Appliances - pays the usual and customary charge when ordered by an attending physician.
- Other Medical Treatment by a licensed practitioner, including adjustment, manipulation or massage in any form, diathermy, bone growth stimulation, ultrasonic, microtherm or heat treatment in any form, not to exceed in the aggregate $2,500 for any one covered accident.
- Charges by a Home Health Agency for home health care services as mandated by Section 38A-493 of the Connecticut General Statutes.
- Medical Expenses incurred by accidental ingestion or consumption of a controlled drug as mandated by Section 38a-492 of the Connecticut General Statutes.
- Medical or Hospital Dental Procedures Expense general anesthesia, nursing and related hospital services provided in conjunction with inpatient, outpatient or one-day dental services if the following conditions are met: a) Services are deemed medically necessary by the treating dentist or oral surgeon, and the patient's primary care physician. b) The patient is either (a) a child who is determined by a licensed dentist, in conjunction with a licensed physician who specializes in primary care, to have a dental condition of significant dental complexity that it requires certain dental procedures to be performed in a hospital; or (b) a person who has a developmental disability, as determined by a licensed physician who specializes in primary care, that places the person at serious risk. The expense of such anesthesia, nursing, and related hospital services will be considered a medical expense and will not be subject to any limits on dental benefits.
Benefits under the Program as the result of any one accident will not exceed $1,000,000 in the aggregate for all covered expenses.
* "Physician" or "Practitioner" means a legally licensed practitioner of the healing arts, including a doctor of medicine, osteopathy, dentistry, chiropractic or podiatry, other than an Insured Person or member of his immediate family, who is practicing within the scope of his license to treat the condition causing loss.
** "Hospital" means a lawfully-operated institution for the care and treatment of injured persons with organized facilities for diagnosis and treatment, medical supervision, surgery and 24-hour nursing service.
This part applies to all benefits
This policy does not cover loss due to: (a) Illness or disease in any form. (b) Intentionally self-inflicted injuries, suicide (sane or insane) or attempted suicide. (c) Air travel, or the use of any device or equipment for aerial navigation, except as a fare-paying passenger on a regularly scheduled commercial airline. (d) Incurred medical expenses to the extent they are covered under Workers' Compensation, or Employer's Liability Act or Law. (e) Injuries resulting from war or any act of war (whether declared or undeclared); participation in a felony, riot or insurrection. (f) Loss incurred while the Insured is serving in the Armed Forces or units auxiliary thereto. (g) Dental care or treatment, except as provided for injury of sound and natural teeth. (h) Treatment administered by any family member or person employed or retained by the school. (i) Eye examinations, eyeglasses, contact lenses, hearing aids or prescriptions or fittings therefor except as provided by the policy. (j) That part of medical expenses payable by an automobile insurance policy. (k) Temporomandibular Joint Dysfunction (TMJ).
Injuries occurring before coverage is in force are not covered.
No benefits are payable under this Plan for loss due to skiing in any form, except as a covered member of a competitive interscholastic skiing team.
In the event the Insured Person sustains an injury for which benefits are payable under more than one Student Accident Insurance Policy or like coverage issued by the Company, coverage shall be deemed to be in effect only under one such Policy, the one affording the greater (or greatest) amount of benefits for the injury.
Important Notice... This is an Excess Plan
The Medical Expense benefit of this Program is an "excess" type benefit. The Policy does not cover treatment or service for which benefits are payable or service is available under any other insurance or medical service plan available to the Insured Person, including, but not limited to, HMO's, PPO's, Workers' Compensation and automobile medical insurance. This does not apply to a plan of insurance by the Connecticut Health Reinsurance Association.
Parents will be supplied with claim forms. When injuries are reported the claim form should be completed and sent within 30 days of loss, or as soon thereafter as reasonably possible to: commercial Travelers, Attn: School Claims, 70 Genesee Street, Utica, NY 13502.
Commercial Travelers Life Insurance Company
70 Genesee Street, Utica, NY 13502
as Policy Form Series No. CTP-7 (CT) (Rev. 08) et al
accident only insurance, does not cover sickness
If you have any questions call: Colonna Insurance Services, LLC
Important: This brochure is a summary of benefits. Complete provisions pertaining to his plan are contained in the mater policy file at the school.
Any provisions of the policy or the brochure which is in conflict with the statutes of the state in which the policy is issued, will be administered to conform with the requirements of the state statutes. Plan available only in Connecticut.