Student Accident Insurance Program

2013 – 2014

Designed for the Students of

SUNY Sullivan

112 College Road
Loch Sheldrake, NY 12759
(845) 434-5750

Policy No. 2013M8A39

103 Executive Dr., Suite 300
New Windsor, NY 12553-6839
(845) 567-1000

This plan is underwritten by:

70 Genesee Street
Utica, NY 13502

As Policy Form: SH-1-88


The following is an outline of the essential provisions of the plan, which are incorporated in the master policy.


Full-Time and Part-Time Students are covered 24 hours a day.


Accident insurance is in effect from August 23, 2013 to August 23, 2014.


When the insured Student requires, commencing within 60 days from the date of accident, any one or more of the following medical services as the result of an accident occurring during the term of insurance, the plan will pay the usual and customary charge for such expenses incurred for any one accident within 104 weeks from the date of the accident, up to:

Maximum Medical Benefit Deductible
Non-Sports $ 2,500 0
Intercollegiate Sports $10,000 $250
  1. Medical and surgical care by a physician (home, hospital, and office visits included).
  2. Hospital care and treatment (including ambulatory surgical and medical centers), as an outpatient or when confined as a bed-patient (not to exceed the normal charges for semi-private accommodations).
  3. Services of a registered graduate nurse (RN) or licensed practical nurse (LPN).
  4. X-rays, laboratory tests, physiotherapy, oxygen and blood transfusions.
  5. Medicines, appliances and medical supplies.
  6. Dental treatment made necessary by injury to natural teeth.
  7. Ambulance expense.

Accident means bodily injury directly caused by specific accidental contact with another body or object during the Insured Person’s term of insurance, and which is unrelated to any pathological, functional, or structural disorder or injury, which first requires medical treatment during the Insured Person’s term of insurance.

Covered Expense means those expenses incurred for the treatment of an accident that:

  1. Are incurred on the approval of a physician
  2. Do not exceed the Usual and Customary Charge for the service or supply provided
  3. Are listed as Covered Expenses in the Benefit Provision.

Physician means a person licensed as such by the state in which he or she practices, other than a member of the Insured Person’s immediate family. A dentist shall be considered a physician when providing treatment for which benefits are payable under the Policy.


If the Insured Student sustains any of the following losses as the result of a covered accident within 52 weeks after the date of accident, the Company will pay the amount shown.

Event Amount
Life $5,000
Double Dismemberment $5,000
Single Dismemberment $5,000
Thumb & index finger (same hand) $1,250

Loss of hand or foot means complete severance through or above the wrist or ankle joint. Loss of an eye means the total permanent loss of sight in the eye.

Principal Sum: $5,000. The Principal Sum is the largest amount payable under this benefit for all losses resulting from any one accident.


The benefits provided in this brochure also apply to Home Health Care Expenses provided by a Home Health Care Agency. The details of this coverage are included in the Policy on file at the College.


The Policy does not cover loss arising out of or resulting from:

  1. Suicide or attempt threat, or any self-inflicted injury.
  2. War or any act of war, whether or not declared.
  3. Participation in a felony, riot or insurrection.
  4. Travel in, or descent from an aircraft, except when a fare-paying passenger.
  5. Service in any armed forces, military reserves or militia.

Nor does the Policy provide benefits for:

  1. Eyeglasses, contact lenses, hearing aids, or examination for same.
  2. Expense for which benefits are payable under any Workers’ Compensation law or similar legislation, or under any mandatory no-fault automobile insurance.
  3. Cosmetic surgery, except reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part.
  4. Treatment provided in a government hospital, unless there is a legal obligation to pay for such service in the absence on insurance.
  5. Treatment or service by any person or facility employed or retained by the school.
  6. Treatment or service provided by an immediate family member or by a member of an Insured Person’s household, for which no charge is normally made.
  7. Dental care or treatment, except for injury to sound natural teeth caused by an accident.
  8. Preventative medicines, serums or vaccines.
  9. Any treatment or service for which benefits are payable or service is available under any other group or blanket insurance or medical service plan available to the Insured Student, (for Intercollegiate sports accidents only.)

In the event of accident the student should consult a doctor and follow the doctor’s instructions.

Claim forms are available at

All claims should be mailed to:

70 Genesee Street
Utica, NY 13502
(800) 756-3702

For a copy of the Company’s Privacy Notice, go to

Representations of this plan must be approved by the Company.


This plan provides ACCIDENT insurance only. It does not provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department.