CLAIM FORM

BSA Accidental Injury Insurance Plan

Insurer

ACE American Insurance Company

Policy number: PTP N00327402

Administrator

Health Special Risk, Inc.

HSR Plaza
4001 North Josey Lane
Carrollton, TX 75007-1520
866-726-8870
Fax 972-492-4946

Coverage

Covers all youth, registered and volunteer leaders, and non-Scouts, non-Scouters and guests who are being encouraged to become registered leaders or Scouts while in attendance at a scheduled activity. The Plan provides year-round coverage for injuries occurring anywhere in the world while:

· Participating in an official Scouting or Learning for Life activity. Seasonal camp staff are also covered during their off-duty hours, subject to the workers’ compensation exclusion.

· Traveling to and from official Scouting or Learning for Life activities.

Definitions

“Injury” means accidental bodily harm sustained by an insured member that results directly and independently from all other causes from a covered accident. The Injury must be caused solely through external and accidental means. All injuries sustained by one person in any one accident, including all related conditions and recurrent symptoms of these injuries, are considered a single Injury.

“Sickness” means any Sickness that requires unscheduled medical treatment during an official Scouting or Learning for Life activity.

Benefits

Loss of Life $10,000 (Includes loss of life resulting from heart failure within 90 days from the date of participating in an approved Boy Scout or Learning for Life activity.)

Loss of Both Hands or Both Arms $20,000

Loss of Both Feet or Both Legs $20,000

Loss of One Hand and One Foot $20,000

Loss of Both Eyes $20,000

Loss of One Limb and One Eye $20,000

Loss of One Hand or One Arm $5,000

Loss of One Foot or One Leg $5,000

Loss of Either Eye $5,000

Loss of Thumb and Index Finger $2,500

Loss of a hand or hands, or a foot or feet, shall mean complete severance through or above the wrist joint or ankle joint, respectively; and loss of an arm or arms, or a leg or legs, shall mean severance at or above the elbow joint or knee joint, respectively; the loss of an eye or eyes shall mean the total permanent loss of the entire sight thereof. Loss of a thumb and index finger shall mean severance of at least one entire phalanx from each digit of the same hand. When injuries result in paraplegia, hemiplegia or quadriplegia Commencing within 60 days after the covered accident and continuing for one year, the Company will pay $10,000 for paraplegia or hemiplegia and $20,000 for quadriplegia.

“Paraplegia” means complete loss of function of the lower extremities of the body with involvement of both legs. “Hemiplegia” means complete loss of function of one side of the body with involvement of the arm and leg. “Quadriplegia” means complete loss of function of both the upper and lower extremities of the body with involvement of both arms and both legs. “Limb” means hand(s), arm(s), foot (feet), or leg(s). In the event of multiple losses or death resulting from any one covered accident, only one benefit is payable…the larger amount applicable.
Accident Medical Expenses up to $15,000

Sickness Medical Expenses up to $7,500

For each sickness or injury, benefits are payable for medical or surgical treatment, prescription drugs or for hospitalization or the exclusive services of a private duty nurse (RN or LPN), which begin within 60 days from the date of the accident or sickness that begins during the covered activity. Benefits will be paid for expenses incurred (subject to the Primary Excess Provision explained below) up to the Usual and Customary charges normally made within the geographic area where treatment is performed.

When medical or surgical treatment is involved, benefits in excess of the first $300 will be payable only for the expenses shown above which are not recoverable under any other insurance policy or service contract. If no other collectible insurance is available, this Primary Excess Provision will not apply. Also, medical coverage under this plan does not provide duplicate benefits when an insured member is also insured under another Boy Scout plan or Learning for Life plan for a national or regional sponsored camp or special event.

Specified Injuries Medical Expenses up to $35,000 will be paid for medically necessary treatment due to:

(a) loss of sight in both eyes

(b) dismemberment of any extremity

(c) paralysis

(d) irreversible coma

(e) entire loss of speech

(f) loss of hearing in both ears

“Dismemberment of any extremity” means complete Severance of hand, foot, arm or, leg. Severance” means the complete separation and dismemberment of the part from the body. “Paralysis” means total loss of use of: a) both upper and lower limbs; upper and lower limbs on one side of the body; one lower limb or one upper limb; or both lower limbs or both upper limbs. “Irreversible Coma” means: (a) state of unconsciousness in which there is a cessation of activity in the central nervous system as demonstrated by an electroencephalogram (using criteria established by the American Electroencephalography Society); and (b) a diagnosis of brain death by the attending doctor.

Dental Treatment. Pays for dental injuries, up to a total of $5,000 for repair, treatment and/or replacement of sound, natural teeth. If, within the 52-week period following the date of the accident, the Insured’s attending dentist certifies that dental treatment and/or replacement must be deferred beyond such 52-week period, the Company will pay the estimated cost of such treatment; however, benefits will not exceed a total of 5,000. This benefit shall be in addition to any other benefits payable under the terms of this Plan.

Ambulance Service. Pays up to $6,000 for air ambulance service when, in the judgment of the duly authorized medical authority or the senior representative of the camp or activity, such service is needed to facilitate treatment of injuries and no other ambulance service is available. Pays for professional ambulance service for surface transportation to a hospital. These benefits shall be in addition to any other benefit payable under the terms of this plan.

Benefits for medical expenses, dental treatment and ambulance services are payable for services or treatment performed and supplies furnished within 52 weeks of the date of the accident or sickness that begins during the covered activity.

Return Transportation Expenses. If a covered injury or sickness requires an insured member to return home from a scheduled activity, up to $1,500 for the transportation expense incurred will be paid – plus the transportation expense for one person to accompany the insured member on such trip, if such accompaniment is recommended by a legally qualified doctor. Benefits will be paid in addition to any other benefits payable under this Plan. In the event the insured member is deceased, this benefit will be payable for a person who accompanies the body, but only if such person is a member of the insured member’s immediate family.

Weekly Disability Indemnity. All registered adult leaders 21 years of age or older (18 years if an Assistant Scoutmaster, Assistant Den Leader, Assistant Cub Master, or Assistant Webelos Den Leader) are eligible for this benefit. When covered injuries result in Total Disability beginning within seven (7) days after the date of an accident, the Company will pay benefits for one day or more during such Total Disability at the rate of $200 for each full week, not to exceed 52 weeks for any one covered accident. Benefits begin on the date of the first medical treatment during Total Disability. (Total Disability means an insured member: (1) if employed, cannot do any work for which he or she is, or may become, qualified by reason of education, experience or training; and (2) if not employed, cannot perform the normal and customary activities of a healthy person of like age and sex.)

Exclusions (what is not covered)

The policy does not cover: (a) the cost of medical or surgical treatment or nursing service by a person employed or retained by the Boy Scouts of America or Learning for Life, or by any immediate family or member of the insured member’s household; (b) any loss caused by suicide or attempted suicide; (c) any loss caused by intentionally self-inflicted injuries; (d) eyeglasses, contact lenses, hearing aids, examinations or prescriptions for them, or repair or replacement thereof; (e) loss caused by war or any act of war, whether declared or not; (f) dental treatment or dental x-rays, except when required as the result of injuries to sound, natural teeth; (g) Injury or Sickness paid or payable by Workers’ Compensation, Employer’s Liability Laws or similar occupational benefits. Hospital benefits are not payable for confinement in an institution not classified as a hospital, or in a hospital or institution or part of a hospital or institution which is licensed or used principally for the treatment or care of drug addicts or alcoholics, or as a clinic, continued or extended care facility, skilled nursing facility, convalescent home, rest home, nursing home or home for the aged.