Health Insurance Plan (Academic Personnel)

1. CONTENTS
   1. Definitions
   2. Premiums
   3. Membership and Classification
   4. Enrollment of Academic Appointees
   5. Days of Hospitalization
   6. Services Provided
   7. Services/Benefits Not Provided
   8. General Provisions
   9. Payment of Hospital Bills
   10. Appendix

SECTION 1 . DEFINITIONS

1. University or AUB means the American University of Beirut.

2. HIP means the Health Insurance Plan of the American University of Beirut.

3. Subscriber means the principal enroller in the Plan.

4. Member means any individual covered by the HIP.

5. Academic appointee means a person engaged in teaching or other academic work at the University as per its applicable rules and regulations.

6. Child means a natural born or a legally adopted dependent, unmarried child, up to the 21st birthdate, living with the subscriber, except when the child is away from home for study.

7. Adult means an unmarried, non-working natural born or legally adopted son or daughter who is 21 to 25 years of age if attending school, and beyond that, only if unable to work for reasons of physical or mental disabilities, and if totally dependent upon and living with the subscriber.

8. Family means the subscriber, his/her spouse and eligible children.

9. Spouse means the husband or wife of the subscriber.

10. Maternity means HIP maternity benefits for persons enrolled for such benefits within 21 days after marriage or at least ten months before normal delivery date, as stated in section Eight item 7.

11. HIP premium is a premium applied to subscribers not covered by the Lebanese National Social Security Fund - Medical and Maternity Branch (hereafter referred to as NSSF).

12. HIP/NSSF premium is a premium applied to subscribers covered by the Lebanese National Social Security Fund - Medical and Maternity Branch.

13. Medical emergency means a sudden, unexpected and unforeseen occurrence of condition resulting in an injury or acute illness requiring immediate attention as determined by the medical profession.

14. Academic appointees who retired prior to July 1, 1998 and who leave or voluntarily resign and surviving spouses are defined in Section Four (A).

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SECTION 2. PREMIUMS

The premium rates are determined by the University and are subject to change from time to time at the sole discretion of the University.

The current schedule of monthly premium is shown in appendix A.

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SECTION THREE - MEMBERSHIP AND CLASSIFICATION

1. All full-time academic appointees engaged for periods over three months are entitled but not required to enroll in the HIP with their spouses, and dependent children under 21 years of age, and eligible adult sons and daughters. A subscriber may enroll alone but if he/she wishes to cover his/her family he/she must include the spouse and all eligible children, but can exclude dependent adults. The enrollment of any new person is subject to the passing of a medical examination by a physician designated by the University to evaluate his/her health status for possible enrollment in the Plan.

2. Academic appointees engaged on half-time or more and for more than nine months are eligible to join the HIP under the same conditions as in (1) above. Part-time academic appointees are not eligible to join the HIP but are eligible to use the University Health Service; exceptions to this rule are Academic appointees holding clinical appointment in the Faculty of Medicine. Their enrollments are at first class rates only.

3. Eligible personnel who opt to join the HIP must fill in the Benefits Coordinator's Office an enrollment form of membership within 21 days from the date of appointment indicating the class, the persons to be covered and any additional optional coverage. Excerpts from rules and regulations governing HIP will be signed by each appointee upon signing his/her contract of employment; uninsured persons are of course, required to pay for their medical and hospital care. After the lapse of 21 days, enrollment will be available if requested in writing only in the following October.

4. University personnel who go on Sabbatical Leaves, Home Leaves, Leaves With Pay or Leaves Without Pay are entitled to continue their HIP membership while on leave. Payment of bills incurred outside AUB Hospital or abroad will in no case exceed a maximum of 80%, in excess of deductibles, of the costs of similar medical care or hospitalization, at the AUB Medical Center. The HIP coverage in this case may be inadequate, accordingly a subscriber on leave as mentioned in the previous paragraph is advised to make private arrangement for adequate health insurance in the place of destination. For coverage during leave without pay, the subscriber has to pay the premium in advance prior to departure, otherwise, he/she would be considered as a new member upon returning from such leave.

5. Membership begins from the date of enrollment. For foreign hire personnel duly engaged from overseas, membership may begin one month before the date when work and salary begin. Membership continues automatically unchanged as long as the subscriber remains eligible under the Plan. No change in class or coverage is allowed unless the subscriber specifically requests a change in writing, and then only in the following October.

6. HIP coverage may be continued at the written request of the subscriber for a period not to exceed one month from the last day of the month in which the contract or employment is terminated.

7. Any change in status, e.g., marriage, birth of a child, adoption of a child, must be reported within a maximum period of 21 days to the Benefits Coordinator's Office in order to take advantage of the benefits available. In such cases, the fee and the benefits begin with the date of the change of status. In case of birth of a child whose parents are members of the HIP, the benefits for the child begin from the fourth day. After the lapse of 21 days, enrollment and coverage will be available if requested in writing and then only in the following October.

8. The University may require the subscriber to sign declarations when in its opinion such declarations would ensure the proper application of the Plan.

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SECTION FOUR - ENROLLMENT OF ACADEMIC APPOINTEES
WHO RETIRED PRIOR TO
JULY 1, 1998
AND WHO LEAVE OR VOLUNTARILY
RESIGN AND SURVIVING SPOUSES

A. DEFINITIONS

1. A retiree is an A.U.B. academic personnel residing in Lebanon who retired from A.U.B. service prior to July 1, 1998 in accordance with the University Regulations after having served at least 15 cumulative years with a minimum of five continuous years immediately preceding retirement.

2. An academic appointee is an A.U.B. academic personnel residing in Lebanon who leaves or voluntarily resigns from AUB service in accordance with the University regulations, who at such time was age 65 or over and had completed 15 years of cumulative service with the last five years in continuous active service at the University or who at such time was age 60 or over and had completed 20 years of cumulative service with the last five years in continuous active service at the University or who at such time was not yet age 60 but had completed 30 years of cumulative service with the last five years in continuous active service at the University, and who had continuously enrolled his/her family in the Plan during such 15, 20 or 30 year period when eligible.

3. A surviving spouse residing in Lebanon is the wife or husband of a deceased retiree or deceased AUB academic appointee who is described in the preceding paragraphs or who had served for at least 15 cumulative years with a minimum of the last five years of continuous active service immediately preceding death while in service.

B. REGULATIONS

1. Enrollment of retirees, academic appointees and surviving spouses (as defined in Section Four A, above) and their families will be in accordance with the general regulations of the Plan.

2. Dependent children of retirees, academic appointees and surviving spouses (as described in Section Four A, above) will be eligible only up to age of 21. Adult children will also be eligible up to the age of 25 if students.

3. Application for enrollment must be submitted in writing within a maximum of one month of the actual date of retirement, leaving or voluntarily resigning from AUB or of the death of the subscriber.

4. Premiums are paid for one year in advance according to rates established by the University.

5. Enrollment is open only to the subscriber and the members of his/her family as at the time of his/her retirement, leaving or voluntary resignation from AUB or death.

6. In case of death of an academic appointee who retired or leaves or voluntarily resigns from AUB, his/her family as at the time of his/her death may apply to continue in the Plan.

7. The enrollment of a surviving spouse who remarries stops at the time of remarriage, together with all other members under his/her subscription in the Plan.

8. Reimbursement for hospitalization or medical services is made only for those living in Lebanon. No reimbursement will be made for any services done outside Lebanon under any circumstances.

9. Once enrollment of an academic appointee who retired or leaves or voluntarily resigns from AUB or of a surviving spouse is discontinued, it may not be reinstated.

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SECTION FIVE - DAYS OF HOSPITALIZATION

1. Members are entitled to thirty days hospital care during the first calendar year of enrollment in the Plan. They are entitled to forty five days during the second year, sixty days during the third year and ninety days thereafter for uninterrupted or consecutive years of enrollment.

2. Days are non-cumulative, i.e., the unused portion of hospital service during any year shall not be cumulative in succeeding years.

3. Maternity benefits are limited to a maximum of three days care, and only when both husband and wife are members. When necessary to stay in hospital beyond three days because of medical complications, the additional days will be deducted from the regular days of care to which the member is entitled.

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SECTION SIX - SERVICES PROVIDED

Except as indicated in Section Seven of this Plan, a member is entitled to the following services as and if provided at the AUB Medical Center:

A. IN HOSPITAL COVERAGE

1. A hospitalized member is entitled to professional medical services within the University, and general hospital services except those listed in Section Seven of the Plan.

2. All necessary incurred hospital charges relating to treatment of illness or injury while the member is hospitalized including maternity, if applicable. Coverage is provided at the AUB Medical Center only, and is 100% in excess of deductibles. However, coverage at other hospitals, and in emergency cases only, is a maximum of 80% reimbursable in excess of deductibles at AUB Medical Center rates (i.e. Hospital and Professional Fee Schedules) as charged to the Plan.

3. New born babies will be covered under the mother's maternity benefits for a maximum of three days. Additional days will be covered by the infant's own membership, if any; otherwise, the subscriber will pay for all charges and costs.

4. Isolation services: these do not cover fees for special nurses and difference in room rates, if any, which must be paid by the member.

5. A maximum of three days hospitalization for diagnostic purposes only of suspected mental illness, alcoholism, substance abuse/addiction.

B. OUT-PATIENT (AMBULATORY) COVERAGE

1. An HIP member is entitled to general or specialist physician consultation services if referred by the University Health Service.

2. An HIP member is entitled to diagnostic X-Ray and Laboratory examinations, therapy treatment (radiotherapy, chemotherapy and physiotherapy), emergency room and other necessary services within the resources of the AUB Medical Center.

3. Mental illness or substance abuse/addiction diagnosis only for a maximum of two clinical visits.

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SECTION SEVEN - SERVICES/BENEFITS NOT PROVIDED

This Plan does not provide for the following services:

1. Private nurses, external appliances and prosthesis, and ambulance services.

2. Prescriptions, medications and medical supplies with respect to out-patients except for:

1. One day surgery, for which the Plan will cover 80% of the costs of the anesthesia and medical supplies provided that 20% which is not covered, does not exceed the deductible Fee of HIP in-patients when admitted to the AUB Hospital.

2. Intravenous medications that are needed to conclude the course of therapy for an acute and self-limited medical condition for which the patient was admitted to the Hospital.

3. Injuries resulting from misconduct. Misconduct shall be interpreted as any willful act or carelessness resulting in injury.

4. Chronic or other conditions or diseases or injuries which existed on or before the date of original enrollment or re-enrollment, unless the member has completed five consecutive years of membership.

5. Pre-existing conditions, diseases or injuries of adults.

6. Pre-enrollment medical examination fees and cost of tests for adults.

7. Any conditions arising from pregnancy unless maternity coverage has been subscribed for in accordance with the regulations.

8. Any injury or illness for which benefits are paid for by the employer under the law.

9. Rest cures, sanitoria, custodial care, quarantine.

10. Cosmetic or plastic surgery unless necessary to correct traumatic injury occurring while insurance is in effect.

11. Dental examination and related X-Ray, extractions, fillings and general dental care and any dental surgery.

12. Visitor expenses or personal choice items (e.g., laundry cleaning, gifts, telephone bills, etc.).

13. Speech therapy, psychiatric or child psychology services.

14. Suicide, self destruction, or intentional self inflicted injury, or any attempt thereat while sane or insane.

15. Alcoholism, the abuse of drugs and like substances, the addiction to and abuse of medicines under no medical supervision and all consequences arising therefrom.

16. Treatment of injuries and sickness consequent to the participation of the insured, either as an amateur or professional, in hazardous sport (e.g., motor or motorcycling race, deep sea diving, scuba-diving, snorkeling, parachuting hand gliding, delta-plane).

17. Abortion that is not medically mandated.

18. Tubal-ligation, as well as all birth control procedures and their consequences. Treatment of impotence and varicocele and their consequences. Fertility, sterility, and all screening tests, medication and treatments related thereto and their consequences. In-vitro and ex-vitro or any other artificial insemination procedures.

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SECTION EIGHT - GENERAL PROVISIONS

The Health Insurance Plan provides medical and hospital care for eligible academic personnel under these regulations. To benefit from the coverage provided for by the Plan, HIP members are required to use exclusively the University Health Service and AUB Hospital for such care. Coverage will be in accordance with the Plan's rules and regulations.

A. IN-PATIENTS

1. Admission to the Hospital under this Plan must be recommended by a University Health Service physician or by a physician on the staff of the American University Hospital having admission privileges. The admitting physician shall determine whether or not a patient requires hospitalization and the attending physician shall determine when a patient is ready for discharge.

2. After securing the admission slip from the doctor the patient should report to the HIP Office in the hospital to complete the "Notification of Expected Admission" and find out if the proposed admission is covered by HIP, or subject to study in the light of the final diagnosis appearing on the medical record. This step may be postponed in case of emergency situation.

3. HIP/NSSF members will be covered by the Plan, in accordance with its rules and regulations for the portion of benefits not granted or covered by NSSF.

4. If accommodations are not available in the class to which a member is a subscriber, the Hospital Administration shall have the right to assign a bed in a lower or higher class without refund or extra charge. If a member requests to be admitted to a class higher than that to which he/she is a subscriber, he/she shall pay the difference in the Hospital charges.

5. In case of emergency hospitalization in a hospital other than AUH, the member shall pay the hospital charges. He/she will then apply to the Benefits Coordinator’s Office who, after proper investigation, will authorize refund of such part of the charges paid as are provided by the Plan. To this effect, the member shall submit original itemized bills and receipts together with a report from the attending physician.
   Payment of such charges to the member will in no case exceed 80% of similar hospitalization in the University Hospital at the preferential rates as charged to the Plan in excess of deductibles.

6. There will be a fixed deductible fee per admission per HIP member which will be determined by the University from time to time as shown in appendix A.

7. Coverage for any condition arising out of pregnancy shall be available for three days. Such a coverage is applicable only if the husband and wife are members, and enrollment for maternity benefits was made within 21 days after marriage. Enrollment for maternity not made within 21 days after marriage may be made in October and to be covered, enrollment must be at least 10 months before the normal delivery date.

8. Once maternity insurance is discontinued by a subscriber for any reason, maternity coverage cannot be reinstated.

9. New born infants of members will be covered by their mother's maternity insurance for three days, and after that, they will be enrolled by the Benefits Coordinator's Office as dependent members upon the subscriber's written request.

10. A subscriber will be entitled to coverage with his/her family, if insured, up to the end of the month when he/she leaves the University, or at his/her option, for a period not to exceed one month from the last day on which he/she leaves the University.

11. Upon marriage or attainment of 21 years of age by any child of a subscriber, membership as a dependent shall terminate automatically at the end of the month during which marriage or attainment of 21 years of age has occurred. Adults, as defined in Section One-7. will be reinsured only upon written request.

12. Premiums will be deducted by the Comptroller from the monthly salary of the subscriber. Full monthly premiums will be charged for coverage of a month or a fraction of a month.

13. Premiums of personnel not receiving salaries will be collected yearly in advance. Subscribers will be notified and requested to pay any increase in premiums.

14. Administration of the Plan and interpretation of its regulations shall rest with the University whose decision will be final and binding.

15. The University reserves the right to change the premiums, conditions and regulations of the HIP at any time without prior notice. Such changes will apply to new members and those already enrolled in the Plan.

16. The University will make no refunds on premiums.

B. OUT-PATIENTS

Coverage of out-patient services of members of the Plan will be 100% of the services performed within the resources of the AUB Medical Center through the University Health Service. In Emergency cases only, reimbursement for medical services provided at other than AUB Medical Center, will be at maximum of 80% of cost calculated at the AUB’s Hospital Fee Schedule rates as charged to the Plan; reimbursement ceiling for professional fees will be equal to those of AUB's Hospital professional fee schedule then in effect. The procedure to be followed for reimbursement is similar to that of Section Eight A-5.

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SECTION NINE - PAYMENT OF HOSPITAL BILLS

1. Hospital bills shall be submitted by the American University Hospital to the Benefits Coordinator’s Office. The Subscriber shall remain obligated for the payment of any charge not covered by the Plan. The University shall deduct any such charges from the subscriber’s salary.

2. Claims for reimbursement for services paid for in a hospital other than the American University Hospital should be mailed or delivered in person to the Benefits Coordinator’s Office within two months from the member’s discharge, otherwise, the member will forfeit his/her right for reimbursement and the claim will be rejected.

3. In the event a member of HIP is also a member of another health insurance plan, the HIP will pay only those items covered by HIP but not by the other plan.

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Appendix A

Monthly Premium Schedule

The Monthly Premium Rates in (L.L.) effective October 1, 2004 are subject to change from time to time at the sole discretion of the University.

The fixed deductible fee per admission per HIP member is as follows:

This appendix may be amended from time to time at the sole discretion of the University

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HIP Premium Rates in (L.L.) effective October 1, 2007 are subject to change from time to time at the sole discretion of the University.

 Section Eight - Part A.6

The fixed deductible fee per admission per HIP member is as follows:

This appendix may be amended from time to time at the sole discretion of the University

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