AYSO ACCIDENT REIMBURSEMENT PLAN

Details on the American Youth Soccer Organization insurance plans, including claims procedures, downloadable forms and Spanish versions, go to National's website at:

http://soccer.org/AdminManagement/Insurance/SAI

Forms include: SAI Brochure (English/Spanish) - SAI Claim Form (English/Spanish) - SAI Claim Form Instructions (English)

It is the responsibility of the parent/guardian of the injured player to acquire the necessary insurance claim forms and submit those forms and all necessary insurance documents explained in the SAI Claim Form Instructions to Health Special Risk, Inc.

NOTE: This page provides a summary of coverage’s only for members registered with the AYSO National Support & Training Center – Please read all explanations.

SAI POLICY LIMITS

The Soccer Accident Insurance ("SAI") underwritten by Federal Insurance Company (CHUBB ) pays medical costs up to $50,000 maximum per claim to an insured person for accidental bodily injuries incurred as a direct result of participation in a covered activity*. This is a Full Excess Policy**, and all claims will be paid on a Usual & Customary *** basis.

All claims must be submitted within 90 days of the injury.

Each claim is subject to a $200 Deductible

Other benefits under the policy are:
  • $10,000 for Accidental Death & Dismemberment
  • $10,000 for dental expenses resulting from accidental injury or loss to sound, natural teeth
  • $50,000 Maximum Medical Expenses
  • $1,000 Physical Therapy and Chiropractic Limit
  • $10,000 Orthopedic Appliance Benefit

Enhanced Coverage Includes

  • Expanded Medical Benefit: The policy will include coverage for Eligible Expenses resulting from conditions (such as blisters, tennis elbow, heat exhaustion, hernia, shin splints, bursitis, stress fractures, chronic soreness or pain, tendonitis, strains, sprains, etc.) which are a normal, foreseeable result of a sports or policyholder function covered under the terms of the policy.
  • Heart or Circulatory System Malfunction Benefit: The policy will include coverage for Eligible Expenses incurred by a Covered Person as a result of heart or circulatory system malfunction which: Is first diagnosed and treated while participating in a Policyholder's covered Sponsored Activity (or within 24 hours after participation); and The Covered Person has not previously received medical advice, diagnosis and care or treatment, including the use of prescription drugs for such heart or circulatory system malfunction. If the Covered Person suffers loss of life resulting from heart or circulatory system malfunction within 90 days from the date of participation in the Policyholder's covered Sponsored Activity, a benefit amount is payable as shown under the Principal Sum of the Accidental Death & Dismemberment Benefit.
  • Pre-existing Injury Benefit: The policy will include coverage for Eligible Expenses resulting from re-injury or aggravation of an injury that occurred prior to the effective date of this policy. In order to be eligible for this coverage, the Covered Person must: Have received a written medical clearance from a Doctor to participate in the covered Policyholder's function or sport; and be participating in a covered Policyholder's function or sport when the re-injury or re-aggravation occurs.
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    WHO IS COVERED?

    All AYSO registered players, coaches, referees, and volunteers are covered for accidental bodily injury while participating in the following sanctioned activities:

    • Scheduled games, tournaments, team practice sessions or other sponsored activities, provided they are under the direct supervision of a team official.
    • Group travel directly to or from such games, tournaments, practice sessions or sponsored activities, provided that players are traveling as a team and a licensed adult driver operates the vehicle.

    If you or your parents are covered by any other health care plan, you must submit your bills to the other plan first. After your other plan has paid their share of the claim, you may then submit any remaining balances to the AYSO plan. Be sure to send copies of all itemized bills and the Explanation of Benefits Form outlining the benefits paid under your primary plan****.

    WHAT IS COVERED?

    • Medical/surgical treatment by a doctor or dentist
    • Services of a licensed or graduate nurse
    • Stays in a hospital

    WHAT IS NOT COVERED?

    • Costs of medical services or treatment given by any persons employed or retained by the insured
    • Any bacterial infection not caused by an accidental cut, wound or food poisoning
    • Declared or undeclared acts of war
    • Any loss caused by or resulting from illness or disease
    • Eyeglasses, contact lenses or Hearing aids
    • Intentionally self-inflicted wounds, suicide (while sane or insane) or attempted suicide

    ADDITIONAL EXPLANATIONS:

    * The Benefit Period under this policy is 104 weeks. This means coverage is provided only for medical or dental expenses incurred within 104 weeks of the date of injury.

    ** Full Excess means you must submit your medical bills to any other applicable health care plan you have in force, prior to making a claim under this policy. If your medical coverage is under an HMO or similar plan, you must follow their rules for obtaining benefits; otherwise no benefits will be paid under this policy.

    *** Usual and Customary means claims will be paid for medical fees and services that do not exceed those generally charged for similar Medical Care in your area.

    **** If there is no other insurance available to the participant, the claim will be processed on a primary basis.

    Health Special Risk, Inc. HSR Plaza
    4100 Medical Parkway Carrollton, TX 75007
    (972) 492-6474

    email: claims@hsri.com

    Note:

    This document provides a summary of coverage’s only. For a full description of the policy terms, conditions and exclusions please refer to the actual policy.

    American Youth Soccer Organization
    National Support & Training Center
    12501 S. Isis Avenue
    Hawthorne, CA 90250
    (800) USA-AYSO – www.soccer.org

     

     

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    Last modified: August 18, 2008