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Lucia Mar USD |  E  5143  Students

Student Accident Coverage   

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TO: Parent(s)/Guardian

SUBJECT: Student Accident Coverage Reporting and Claim Filing Procedure

Student Accident Coverage is SECONDARY to any other insurance which provides medical benefits to your child including Healthy Families. SISC is primary to Medi-Cal and Tricare. A claim must be filed with your primary insurance carrier (e.g., Blue Cross, Blue Shield) at the same time you file a Student Accident Coverage claim. If you subscribe to an HMO (Health Maintenance Organization), you must use it.

If you have primary insurance, a copy of the "Explanation of Benefits" (how your insurance has processed the claim) from your insurance carrier is needed to process the Student Accident Claim.

Note: Student Accident Coverage has a maximum benefit of $2,500.00 for services rendered as a result of bodily injury. Benefits are only payable for services rendered within one year of the date of the injury. Physical therapy and chiropractic services are subject to additional limitations. The completed SISC claim form must be submitted to SISC within one year (52 weeks) of the date of injury. This is a brief outline of the plan and is not to be accepted or construed as a substitute for the provisions of the contract.

ALL SECTIONS NEED TO BE COMPLETED OR YOUR CLAIM WILL BE RETURNED.

1. Report accidental injury to appropriate school official immediately.

2. Have designated school employee complete and sign the school's section of the claim form.

3. The claim form must be filled out completely¬óall areas need the specific information which is requested and the parents/guardians need to sign all the appropriate spaces.

4. Give a copy of the completed claim form to all providers to be billed directly to SISC.

OR

5. Send completed claim form, itemized bills and Explanations of Benefits (EOBs) if applicable to:

SISC - Student Accident Coverage

P.O. Box 1847

Bakersfield, CA 93303-1847

For your personal records, please keep a copy of all submitted paperwork.

Any questions concerning Student Accident Coverage should be directed to this office at (661) 636-4710.

Please See District Material in District Office for

"Student Accident Coverage Reporting and Claim Filing Procedures" Spanish Version

Exhibit LUCIA MAR UNIFIED SCHOOL DISTRICT

version: June 20, 2017 Arroyo Grande, California