Minerva Central School

Small Personal Special

School Insurance

Minerva Central School uses Pupil Benefits, Inc. as our student insurance. This is a "Supplemental" Insurance. This means that Pupil Benefits will pay for most accidents/injuries that happen at school, or during a school-sponsored event, AFTER the student's own insurance covers what they will. The only time this does not apply is if the student has no insurance or is covered by Medicaid. An accident report is filled out for all accidents/injuries that occur at school, providing the student actually notifies someone that there has been an injury. These accident reports are filed in the health office. Parents need to ask for a Medical Claim Form to be brought to the physician when they go. Parents have a section of the claim form they need to fill out as well. The Medical Claim Form is returned to the Health Office to be mailed with a copy of the Accident Report to the insurance company. The insurance company will notify parents directly. Please be aware, there are some things Pupil Benefits will not cover, regardless. I have copied the brochure that is handed out with the Medical Claims Forms and attached it below. This gives a better overview of our insurance plan. Please feel free to call or e-mail me with any questions.

When covered, medical, dental and hospital expense incurred exceeds the scheduled indemnities listed below, catastrophe expense will cover 80% of those expenses, less a deductible of $100.00 to the extent that such expenses are reasonable, necessary, and customary up to an aggregate maximum of $50,000.00; maximum aggregate dental benefits will be limited to $1000.00 when treatment extends over 12 months from the date of injury. Benefits paid up to 3 years from the date of injury (except Open Dental). Anesthesia Services-20% of the scheduled indemnity Ambulance service - $50.00 Inpatient Confinement-$270.00 Eyeglasses-(loss related to bodily injury)-$100.00 Treatment per office visit-first visit - $35.00 Subsequent visits-$25.00 Strapping, injection, suture-$3.00 Physiotherapy treatment(first five visits)-$20.00 Consultation not rendered by treating MD-$50.00 Application of cast(one per claim) - elbow to finger-$40.00 ankle(foot to mid-leg)-$40.00 Hand to wrist-$30.00 Knee(foot and mid-thigh)-$60.00 Shoulder to hand - $50.00 Sprain, Contusion, Laceration-$120.00 Concussion-$90.00 Excision of complete nail-$60.00 Eye (minor)-$50.00 Knee (cartilage or ligament)-$120.00 Knee (operative)-$370.00 Exploratory Laparotomy-$270.00 Nephrectomy or Splenectomy-$420.00 *X-rays (max of 3 x-rays, each according to schedule); A single finger or toe-$31.00 Hand, wrist, arm, elbow, humerus, ankle, foot, leg, knee, femur-$38.00 Shoulder, clavicle or scapula-$42.00 Nasal bones, mandible, orbit-$38.00 Pelvis, hip joint, chest, spine-$51.00 Skull-$56.00 CAT Scan-$110.00 M.R.I. - $200.00	Medical Indemnity Schedule Dislocations Hip-closed-$180.00 - open-$320.00 Patella-closed-$80.00 - open-$180.00 Ankle-closed-$100.00 -$220.00 Astragalus-closed-$120.00open-$220.00 Toe-closed $50.00 open-$80.00 Complete Fractures Skull-(operative)-special consideration Nose-simple-$70.00 Nose-compound or displaced-$170.00 Maxilla or Mandible closed$170.00 open-$320.00 Clavicle or Scapula closed-$100.00-open-$220.00 Sternum closed-$70.00-open-$220.00 Ribs-$60.00 Vertebrae-transverse process-$90.00 Vertebrae-body or lamina-$220.00 open-special consideration Sacrum and,or Coccyx closed-$120.00-open-$170.00 Pelvis-one bone closed-$170.00 open-$220.00 Pelvis-multiple closed-$220.00 open-$320.00 Complete Arm Fractures Humerus or elbow-(entire joint) closed-$220.00-open-$320.00 Condyle only-$120.00 Radius or Ulna closed-$140.00-open-$220.00 Radius and Ulna without manipulation-$140.00 with manipulation-closed-$220.00 open-$320.00 Colles without manipulation-$100.00 with manipulation-closed-$140.00- open-$220.00 Carpals or Metacarpals(1st) closed-$120.00 open-$220.00 Metacarpals-(2-5) closed-$100.00-open-$180.00 Finger-one closed-$70.00-open-$120.00 Finger-multiple closed-$90.00-open-$120.00 Complete Leg Fractures Femur-closed-$320.00-open-$420.00 Femoral or Tibial Condyle or both without manipulation-closed-$140.00-with manipulation-closed-$250.00-open-$470.00 Patella-closed-$120.00-open-$220.00 Tibia-shaft-closed-$190.00-open-$290.00 Tibia-malleolus(medial)-closed-$140.00-open-$260.00 Fibula-shaft-closed-$120.00-open-$170.00 Fibula-malleolus(lateral)-closed-$120.00-open-$190.00 Tibia and Fibula-closed-$240.00-open-340.00 Multiple malleolar-closed-$220.00-open-$320.00 Astragalus or Os Calcis-closed-$170.00-open-$270.00 Tarsals-closed-$120.00-open-$180.00 Metatarsals-closed-$100.00-open-$170.00 Toe-one-closed-$60.00-open-$100.00 Toe-multiple-closed-$80.00-open-$100.00	Dislocations Shoulder-closed-$100 open-$270 Elbow or Wrist-closed-$100.00-open- $200.00 Finger-closed-$50.00 open-$120.00 Accidental Death and Dismemberment* Life.................................................$5,000.00 Two or more members...............$10,000.00 One member.................................$5,000.00 Dental Indemnity Schedule Intraoral periapical-first film-$6.00 Each additional film - $4.00 Complete intraoral series of periapicals -$36.00 Removal of the tooth, simple - $22.00 Removal of the tooth, surgical-$30.00 Apicoectomy (root amputation)- $70.00 Extirpation of pulp and fillings of one root canal and root canal closure (per tooth, including x-rays)-$100.00 Each additional canal same tooth-$40.00 Amalgam filling-each surface up to three - $20.00 Acrylic filling-Composite/Acid Etch-$30.00 Silicate cement filling-$26.00 Gold inlay for one surface-$70.00 Each additional surface up to three - $25.00 Cast metal core-$50.00 Recementing restoration$20.00 Acrylic jacket crown-$90.00 Acrylic veneer crown-$110.00 Porcelain jacket crown-$135.00 Porcelain veneer crown-$160.00 Porcelain fused to metal crown-$180.00 Cast gold crown-$140.00 Cast gold facings-$145.00 Acrylic partial denture without clasps-$110.00 Stainless Steel Crown-$30.00 Ligation(wiring of loosened traumatized teeth)-$30.00 Dentures - special consideration Treatment provided by a chiropractor is covered. No benefits will be paid for dental injuries unless a mouth and tooth protector is in place at the time of injury in Tackle football, interscholastic ice hockey, lacrosse, and girl's field hockey. Replacement or repairs of previous restorations will be limited to 50% of the scheduled indemnity. All OPEN dental claims as authorized must be completed within 90 days after the insuree is graduated or left high school.
IMPORTANT NOTICE: THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS

WHAT YOU NEED TO DO

*When your child is injured in a school-sponsored activity, you have 45 days from the date of injury to seek treatment.

*Obtain a claim form from the District and submit itemized bills to Pupil Benefits Plan no later than one year from the date of injury, even if treatment is not completed. This plan is a secondary, non-duplicating policy. If you have medical or dental insurance that covers your child, charges must be submitted to your primary insurance first. Submit the explanation of benefits or rejection from your carrier along with itemized bills to the Pupil Benefits Plan.

*Expenses resulting from injuries to sound and natural teeth should be submitted to your medical insurance even though dental coverage is not available. When an accidental dental injury occurs, your medical coverage will consider charges first.

*Please answer all questions on the claim form. Blank spaces are not acceptable. Please write legibly.

*If your child is injured while participating in an interscholastic sport, the physician's discharge date and allowance to return to participation terminate the benefits for that injury. Coverage will be reactivated on that date for any subsequent injury.

*When submitting additional bills at a later date, including the school district, child's name, and date of injury.

WHAT YOU NEED TO KNOW

*PLEASE READ THE FOLLOWING:

*Unfortunately, there are some exclusions and limitations under this plan. There are no benefits provided for cosmetic surgery. Please note cosmetic surgery does not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part. There are no benefits provided for intentionally self-inflicted injuries or injuries sustained during participation in a felony or riot. This policy does not provide coverage for sickness, pre-existing conditions, disease, or orthodontia. There are no benefits provided for drugs, supplies, or orthopedic appliances including crutches, braces, beds, wheelchairs, etc. Pupil Benefits plan provides student accident insurance only.

*Pupil Benefits Plan's student accident insurance assures prompt medical attention and assists with expenses which revert to the parent, since no school may be held legally responsible for them. If medical bills are in excess of our benefit payments, the difference is the responsibility of the parents.

*If you need special assistance, please call our office. We will be happy to help you in whatever way we can.

PUPIL BENEFITS PLAN, INC.

101 Dutch Meadows Lane

Glenville, NY 12302

Office(518)377-5144

1-800-393-3301

FAX(518)377-3291

http://www.pupilbenefits.com/

Last Modified on December 9, 2021