INSURANCE AND CLAIM FORMS:
Procedures for Filing an Athletic Injury Claim
ATHLETIC INJURY PLAN:
Medical Services Responsibilities
Penn State Mont Alto provides its varsity student-athletes with medical care and treatment for illness or injury suffered while participating in supervised practice or intercollegiate competition sponsored by Penn State Mont Alto. The University’s athletic insurance injury plan is designed to be in excess to the student-athlete’s health insurance plan.
Student-athletes who do not have a health insurance plan must demonstrate the lack of primary health insurance by completing and notarizing an Affidavit of No Insurance.
Insurance
The University provides athletic injury secondary insurance for injuries occurring during one of the following covered activities:
a. Supervised practice
b. Scheduled and USCAA sanctioned games, tournaments and exhibition games
c. Special events sponsored by the University
Under current rules, the University may not cover any cost of injuries that are not a result of organized practice or competition. When an injury occurs during practice or competition, the following guidelines are to be followed:
a. Charges incurred for a covered injury requiring medical, dental or vision treatment will be first applied to the student-athletes health insurance plan. Any deductible or portion of the reimbursable charges not covered by the student-athlete’s health plan shall be submitted to the University’s athletic injury plan.
b. Parents or legal guardians will be notified of a claim. If the parents’ or legal guardians’ insurance company send the check to them and not directly to the medical provider, it will be the responsibility of the parents or legal guardian to pay the medical provider.
c. The athletic injury program’s basic coverage is excess of any and all primary health, dental and vision insurance. This coverage will be for related medical expenses incurred within 104 weeks from the date of the covered injury.
d. Student-athletes who quit or who are dropped from the team are not eligible for coverage by the University’s athletic injury plan.
Intercollegiate Athletics will not provide medical service for the following illnesses or injuries:
a. Illness or injury occurring in practice or competition which is not supervised or sponsored by Intercollegiate Athletics.
b. Illness or injury occurring after the completion of athletic eligibility, unless the student-athlete was under treatment at the completion of the student-athlete’s participation and has remained under such treatment.
c. Normal dental care such as treatment for cavities, cleaning, impaction and corrections of congenital defects.
d. Contact lenses.
e. Immunization or desensitization (allergy) injections.
HOW TO FILE A CLAIM
1. Notify Athletic Trainer of Injury
2. Complete a claim form
a. Claim forms are available in the Athletic trainer’s office in the MAC or online.
b. The claim form must be completed in full. Please be sure to detail accident information, include part of the body injured, how the injury occurred and the particular sport. Students who are covered under their parent’s or legal guardians insurance must provide all requested information on the claim form under Parent/Guardian Information and Sections A and B. If the student carries their own insurance that information goes in Section A. A separate claim form is required for each injury.
3. Submit all fully ITEMIZED bills to the athletic trainer in person, via email (kbc13@psu.edu) or via Fax attn: athletic training (717-749-6179).
a. Submit itemized copies of all applicable bills, including those bills under any deductible your plan may have. Also, include those bills paid partially or in full by other insurance. Bills showing “Balance Forward” or “Balance Due” are not acceptable
b. An itemized bill indicates the provider of service’s full name and mailing address, type of service, date of service, fee charged and diagnosis. To assure quick processing, please be sure that the bill and the insurance statements submitted are for the same item.
c. Along with the itemized bill, included a copy of the explanation of benefits statement from the other insurance carrier. If any or all benefits are denied by other insurance, we will need a copy of the denial showing the reason charges were denied.
