ESBD_File_352335_in-force insurance policy.pdf

AH51055E-TX 1

Berkley Life and Health Insurance Company Urbandale, Iowa Underwriting Office:

2445 Kuser Road, Suite 201 Hamilton Square, NJ 08690

ADMINISTRATIVE CHANGE RIDER

This Rider is attached to and made a part of Policy Number COL L004000065908 issued to Angelo State University (the Policyholder).

Effective 08/01/2023, the Policy is renewed and SCHEDULE OF BENEFITS in the Policy is amended as follows:

POLICYHOLDER: Angelo State University

POLICY EFFECTIVE DATE: 08/01/2023

POLICY NUMBER: COL L004000065909

POLICY PERIOD: 08/01/2023 to 08/01/2024

CLASSES OF ELIGIBLE PERSONS:

A person may be covered only under one Class of Eligible Persons even though He or She may be eligible under more than one class.

Class 1 All intercollegiate student athletes, managers, trainers and coaches of the Policyholder.

PREMIUMS

Total Amount Due: $14,175.00

Premium Schedule: Annual paid 30 days From the Effective Date

AGGREGATE LIMIT OF LIABILITY:

Benefit Maximum $1,000,000 Applies During Per Covered Accident Applies To Accidental Death & Dismemberment Benefits only

HAZARDS INSURED AGAINST:

Class Description of Hazard

Urbandale, Iowa

Administrative Office: 2445 Kuser Road, Suite 201, Hamilton Square, NJ 08690 A Berkley Company

Blanket Accident Policy

Policyholder: Angelo State University

Policy Number: SIC L00400659 001

Effective Date: August 1, 2015

State of Issue: Texas

This Policy is a legal contract between the Policyholder and Berkley Life and Health Insurance Company (herein referenced as “the Company”). The Company agrees to provide insurance to the Policyholder, in exchange for the payment of the required premium. Coverage is subject to the terms and conditions described in this Policy.

This Policy and the coverage provided by it become effective at 12:01 A.M. at the address of the Policyholder on the Policy Effective Date shown above. It continues in effect in accordance with the provisions set forth in this Policy.

This Policy is governed by the laws of the state of Texas.

Signed for the Company:

President Secretary

THIS IS A BLANKET ACCIDENT INSURANCE POLICY.

THE POLICY DOES NOT PAY BENEFITS FOR LOSSES CAUSED BY SICKNESS.

THIS IS A LIMITED POLICY.

PLEASE READ THE POLICY CAREFULLY.

THIS IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES

NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING

THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE

BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION

LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT

PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE

FILED AND POSTED.

AH51051E TX 1 TX – College Sports Only Excess (1/12)

TABLE OF CONTENTS

Title Page

SCHEDULE OF BENEFITS

DEFINITIONS

ELIGIBILITY FOR INSURANCE

EFFECTIVE DATE OF INSURANCE

TERMINATION DATE OF INSURANCE

PREMIUMS

HAZARDS INSURED AGAINST

DESCRIPTION OF BENEFITS

EXCLUSIONS

CLAIMS PROVISIONS

GENERAL POLICY PROVISIONS

AH51051E TX 2 TX – College Sports Only Excess (1/12)

SCHEDULE OF BENEFITS

POLICYHOLDER: Angelo State University

POLICY EFFECTIVE DATE: August 1, 2015

POLICY NUMBER: SIC L00400659 001

PREMIUM DUE DATE: Annual in advance

POLICY PERIOD: August 1, 2015 to August 1, 2016

CLASSES OF ELIGIBLE PERSONS:

A person may be covered only under one Class of Eligible Persons even though He or She may be eligible under more than one class.

Class 1 All intercollegiate Student Athletes, Managers, Trainers and Coaches of the Policyholder

PREMIUMS - $18,000

AGGREGATE LIMIT OF LIABILITY:

Benefit Maximum $1,000,000 Applies During per Covered Accident.

Applies To Accidental Death & Dismemberment Benefits only

HAZARDS INSURED AGAINST:

Class Description of Hazard Class 1 Sports Coverage

Covered Activity(ies):

Class 1 Policyholder Supervised and Sponsored intercollegiate play, practice, conditioning and authorized team travel to and from events for the following sports:

Men’s baseball, men’s and women’s basketball, women’s cheerleading, men’s and women’s cross country, men’s football, women’s golf, women’s soccer, women’s softball, men’s and women’s student trainers, student managers, student coaches, men’s and women’s track & field, ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

Class 1 Principal Sum: $10,000 Time Period for Loss: 365 days

AH51051E TX 3 TX – College Sports Only Excess (1/12)

ACCIDENT MEDICAL AND DENTAL EXPENSE BENEFIT

Total Benefit Maximum for all Accident Medical $90,000 Loss Period (first Covered Expenses must be incurred within): 180 days after the Covered Accident.

Benefit Period: 104 weeks Aggregate Deductible $120,000 Deductible: $0 Benefit Percentage: 100% Terms of Payment: Full Excess Dental Benefits: 100% of Accident Medical Benefit

Accident Medical Expense benefits may be available on an allocated or unallocated basis as shown, that is to say there may be specific limits or coinsurance rates on certain Covered Expenses (allocated) or all Covered Expenses may be subject to the same maximum limit and coinsurance factor (unallocated).

Any Deductibles, Coinsurance, Co-payments, Benefit Periods, and Benefit Maximums apply on a per Covered Person, per Covered Accident basis.

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DEFINITIONS

The male pronoun includes the female whenever used.

For the purposes of this Policy the capitalized terms used herein are defined as follows:

ACCIDENT means a sudden, unexpected even that results in Injury to the Covered Person.

BENEFIT PERIOD means the period of time, as stated on the Schedule of Benefits, between the date of the Accident causing the Injury for which benefits are payable and the date after which no further benefits will be paid.

COVERED ACCIDENT means an Accident that occurs while coverage is in force for a Covered Person and results in a Covered Loss/Injury for which benefits are payable.

COVERED LOSS/INJURY or COVERED LOSSES/INJURY means an accidental death, dismemberment or other Injury covered under this Policy and indicated on the Schedule of Covered Losses/Injury.

COVERED PERSON means an eligible person who is within the covered class(es) listed in the Policy, who is a U.S citizen residing in the United States, or if not a U.S. citizen, resides permanently in the United States, and for whom the required premium is paid when due.

DEDUCTIBLE means the dollar amount of Covered Expenses that must be incurred by the Covered Person as an out-of-pocket expense for each Accident, before Accident Medical Expense Benefits and/or other Additional Benefits paid on an expense incurred basis are payable under this Policy. Only one Deductible will apply to the Covered Person and his or her Dependents if Injured in the same Covered Accident.

EMERGENCY CARE means health care services provided in a Hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition or Injury is of such a nature that failure to get immediate medical care could result in:

1) Placing the patient’s health in serious jeopardy;

2) Serious impairment of bodily functions;

3) Serious dysfunction of any bodily organ or part;

4) Serious disfigurement; or

5) In the case of a pregnant woman, serious jeopardy to the health of the fetus.

HOSPITAL means an institution that:

1) operates as a Hospital pursuant to law for the care, treatment and providing in-patient services for sick or injured persons;

2) provides 24-hour nursing service by registered nurses on duty or call;

3) has a staff of one or more licensed Physicians available at all times;

4) provides organized facilities for diagnosis, treatment and surgery, either

a) on its premises; or

b) in facilities available to it, on a pre-arranged basis;

5) is not primarily a nursing care facility, rest home, convalescent home or similar establishment, or any separate ward, wing or section of a Hospital used as such; and

6) is not a place for drug addicts, alcoholics or the aged.

We will not deny a claim for services solely because the Hospital lacks major surgical facilities and is primarily of a rehabilitative nature, if such rehabilitation is specifically for the treatment of a physical disability, and the Hospital is accredited by any one of the following:

AH51051E TX 5 TX – College Sports Only Excess (1/12)

1) the Joint Commission of Accreditation of Hospitals; or

2) the American Osteopathic Association; or

3) the Commission on the Accreditation of Rehabilitative Facilities.

HOSPITAL CONFINED means a stay of 24 or more consecutive hours as a registered resident bed-patient in a Hospital.

IMMEDIATE FAMILY means the Covered Person’s parent, grandparent, spouse, child(ren) (includes legally adopted or step child(ren), brother, sister, step-child(ren), grandchild(ren), or in-laws.

INJURY means bodily injury caused by an Accident. It must result, directly and independently of all other causes, in a Covered Loss.

MEDICALLY NECESSARY means a condition requiring Emergency Care.

PHYSICIAN means a person who is a qualified practitioner of the healing arts, including an acupuncturist, advanced practice nurse, audiologist, chemical dependency counselor, chiropractor, dentist, dietitian, hearing instrument fitter and dispenser, licensed clinical social worker, licensed professional counselor, marriage and family therapist, occupational therapist, optometrist, physical therapist, physician, physician assistant, podiatrist, psychological associate, psychologist, speech-language pathologist and surgical assistant. As such, he or she must be acting within the scope of his/her license under the laws in the state in which he or she practices and providing only those medical services which are within the scope of his/her license or certificate. It does not include a Covered Person, a Covered Person’s spouse, son, daughter, father, mother, brother or sister or other relative.

TOTAL DISABILITY or TOTALLY DISABLED means the Covered Person is completely unable to perform all of the material and substantial duties and functions of his occupation and any other gainful occupation in which he earns substantially the same compensation earned prior to disability. The inability must be as a result of Injury.

If not employed, it means the Covered Person is unable to perform the normal and customary activities of a healthy person of like age and sex due to a Covered Accident.

USUAL AND CUSTOMARY CHARGES means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided.

WE, OUR, US means Berkley Life and Health Insurance Company underwriting this insurance.

YOU, YOUR, YOURS, HE or SHE means the Covered Person who meets the eligibility requirements of the Policy and whose insurance under the Policy is in force.

ELIGIBILITY FOR INSURANCE

If the Covered Person is in one of the classes of Eligible Persons shown on the Policy Schedule of Benefits, he or she is eligible to be covered on the Policy Effective Date. We retain the right to investigate eligibility status and attendance records to verify eligibility requirements are met. If We discover the eligibility requirements are not met, Our only obligation is to refund any premium paid for that person.

EFFECTIVE DATE OF INSURANCE

Policy Effective Date. This Policy begins on the Policy Effective Date shown in the Schedule of Benefits at 12:01 A.M. at the address of the Policyholder.

AH51051E TX 6 TX – College Sports Only Excess (1/12)

Covered Person’s Effective Date

A Covered Person’s coverage under this Policy begins on the later of:

1) the Policy Effective Date; or

2) the date such person becomes eligible, as described in the Schedule of Benefits.

TERMINATION DATE OF INSURANCE

Policy Termination Date Termination takes effect at 12:01 A.M. time at the address of the Policyholder on the date of termination.

Termination by the Policyholder or by the Company will be without prejudice to any claims originating prior to the date of termination.

This Policy terminates automatically on the earlier of:

1) The Policy Termination Date shown in this Policy; or

2) The premium due date if premiums are not paid when due subject to any grace period provided in the Section

V - Premium.

Failure by the Policyholder to pay all required premiums due by the last day of the grace period shall be deemed notice by the Policyholder to the Company to terminate this Policy on the last day of the period for which premiums have been paid.

This Policy may be terminated by the Policyholder or the Company as of any premium due date or Policy Anniversary Date by giving written notice to the other at least 60 days prior to such date.

The Policyholder and the Company may terminate this Policy at any time by written mutual consent.

If premiums have been paid beyond the termination date, the Company will refund the excess; or if premiums have been paid short of the termination date, the Policyholder will owe the Company the difference.

Covered Person’s Termination Date A Covered Person’s coverage under this Policy ends on the earliest of:

1) The date this Policy terminates;

2) The date the Covered Person enters full-time active duty in the armed forces of any country or international authority;

3) The date the Covered Person ceases to be eligible as described in the Policy provided all required premiums are paid; or

4) The last day of the period for which premiums have been paid.

Extension of Benefits Termination of coverage will not affect any claim that began while the coverage was in force. If a Covered Person was Totally Disabled on the date coverage would otherwise terminate, benefits will be continued until:

1) 90 days elapse;

2) The date that the maximum amount of benefits have been paid;

3) The date that the Covered Person ceases to be Totally Disabled; or

4) The effective date of replacement coverage of equivalent or greater benefits provided by a succeeding carrier, but only if the replacement coverage covers the Injury causing the Total Disability without limitation due to the Injury having commenced prior to the effective date of the replacement coverage;

whichever first occurs.

AH51051E TX 7 TX – College Sports Only Excess (1/12)

Only benefits for the Injury causing the Total Disability are continued. No benefits are payable with respect to any other Injury.

PREMIUMS

The Company provides insurance in return for premium payments. The premium showed in the Schedule of Benefits is payable to the Company in the manner described and is based on rates currently in force, the plan, and the amount of insurance in force. Premium is due on the Policy Effective Date. After that, premium will be due monthly unless otherwise stated in the Policy.

The Company has the right to rely upon the accuracy of the Policyholder’s calculations and to require the Policyholder to furnish a census from time to time but not more than twice in a 12-month period. If, at any time, it is determined that additional premium or a premium credit is due, the Policyholder will pay the additional premium or apply the premium credit at the next premium due date.

If any premium payment is not paid when due, the Policy will be cancelled as of the premium due date, except as provided under the Grace Period section.

Changes in Premium Rate Not less than 60 days before the date on which a premium rate increase takes effect, We shall give written notice to the Policyholder of:

1) the amount of the increase; and

2) the date on which the increase is to take effect.

Grace Period A grace period of 31 days will be allowed for the payment of premium after the first premium. During the grace period, this Policy will be in force and We will continue to be liable for valid claims for covered expenses incurred before the end of the grace period. If at least 90 days prior to the premium due date We send written notice to the Policyholder of Our intent not to renew this Policy, the grace period will not apply to any period after the date the non-renewal is to be effective. If the Policyholder tells Us in writing that the Policy will not be renewed, the grace period will not apply after the date the non-renewal is to be effective. If the premium is not paid by the end of the grace period, the Policy will terminate on that date. The Policyholder will continue to be liable to Us for any unpaid premiums in addition to the premiums for the grace period.

HAZARDS INSURED AGAINST

We will pay benefits described in this Policy when a Covered Person suffers a loss or Injury as a result of a Covered Accident during one of the Covered Activities listed in the Schedule of Benefits. Unless otherwise specified, We pay benefits only once for any one Covered Accident, even if it is covered by more than one Hazard.

SPORTS COVERAGE

We will pay the benefits described in the Policy for an Accident which occurs while a Covered Person is:

(1) taking part in:

(a) a regularly scheduled athletic game or competition; or

(b) a practice session for an athletic team or club; or

(2) traveling to or from such a game, competition or practice session provided he is;

(a) traveling with the athletic team or club; and

(b) under the direct and immediate supervision of:

(i) the athletic team or club; or

AH51051E TX 8 TX – College Sports Only Excess (1/12)

(ii) an adult authorized by the athletic team or club; or

(3) traveling directly, without interruption:

(a) between his home and a scheduled game, competition or practice session;

(b) in a vehicle which is:

(i) designated or furnished by the athletic team or club;

(ii) operated by a properly licensed, adult driver, or

(iii) under the direct supervision of the athletic team or club; or

(c) in a vehicle other than that described in (3)(b) when operated by a properly licensed driver.

Travel time includes the time:

(1) to or from home, a scheduled game, competition or practice session;

(2) before required attendance time;

(3) after the Covered Person is dismissed; and

(4) after the Covered Person completes extra duties assigned by the Policyholder.

Conditions which result over a period of time (such as blisters, tennis elbow, heat exhaustion, hernia, etc.), and which are a normal, foreseeable result of the sport, are not covered. These items are considered a sickness and are not covered.

Unless otherwise stated in the Schedule of Benefits, We will pay benefits for a Covered Loss/Injury, only once, even if coverage was provided under more than one Hazard.

DESCRIPTION OF BENEFITS

All benefits payable are shown in the Schedule of Benefits.

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT

If Injury to the Covered Person results in any of the Covered Losses/Injury shown below, within the Time Period for Loss as shown in Schedule of Benefits from the date of the Covered Accident that caused the Injury, the Company will pay the percentage of the Principal Sum (Amount of Insurance) shown below for that loss. The Principal Sum (Amount of Insurance) is shown in the Schedule of Benefits. If multiple losses occur, only one Benefit, the largest, will be paid for all losses due to the same Covered Accident.

Schedule of Covered Losses/Injury Loss of: Benefit:

(Percentage of Principal Sum/Amount of Insurance)

Life ...................................................................................................... 100% Two or More Members ....................................................................... 100% One Member ......................................................................................... 50% Thumb and Index Finger of the Same Hand ........................................ 25% Four fingers of the Same Hand ............................................................ 25%

“Member” means Loss of Hand or Foot, Loss of Arm or Leg, Loss of Sight, Loss of Speech and Loss of Hearing.

“Loss of a hand or foot” means complete severance through or above the wrist or ankle joint. “Loss of Arm or Leg” means complete Severance through or above the elbow or knee joint. “Loss of sight” means total and permanent loss of sight of one/both eyes that is irrecoverable, including by surgical and artificial means. “Loss of speech” means total and permanent loss of audible communication that is irrecoverable by natural, surgical or artificial means. “Loss of hearing” means permanent total deafness in both ears such that it cannot be corrected by any aid or device. “Loss of thumb and index finger of the same hand” means complete severance of each through

AH51051E TX 9 TX – College Sports Only Excess (1/12) or above the metacarpophalangeal joint of both digits of the same hand. Severance means the complete separation and dismemberment of the part from the body.

Aggregate Limit of Liability The maximum amount the Company will pay for all Covered Losses/Injury resulting from the same Accident will not exceed the Aggregate Limit of Liability as described in the Schedule of Benefits.

If the total amount payable for all Covered Losses/Injury in any one Accident exceeds the Aggregate Limit of Liability, each Covered Person’s Covered Loss/Injury will be paid at the same ratio that the Aggregate Limit of Liability has to the total amount of all Covered Losses/Injury. The Company shall not be liable for amounts in excess of the Aggregate Limit of Liability.

ACCIDENT MEDICAL AND DENTAL EXPENSE BENEFIT

We will pay Accident Medical and Dental Expense Benefits for Covered Expenses that result directly, and from no other cause, from a Covered Accident. These benefits are subject to the Deductibles, Coinsurance Factors, Co-payments, Benefit Periods, Benefit Maximums and other terms or limits shown below and in the Schedule of Benefits.

Accident Medical Expense Benefits are only payable:

1) for Usual and Customary Charges incurred after the Deductible has been met;

2) for those Medically Necessary Covered Expenses incurred by or on behalf of the Covered Person;

3) for Covered Expenses incurred within 365 days after the date of the Covered Accident.

No benefits will be paid for any expenses incurred that are in excess of Usual and Customary Charges.

Covered Medical Expenses, from a Covered Accident, include:

1) Hospital room and board expenses: the daily room rate when a Covered Person is Hospital Confined and general nursing care is provided and charged for by the Hospital. In computing the number of days payable under this benefit, the date of admission will be counted, but not the date of discharge.

2) Ancillary Hospital expenses: services and supplies including operating room, laboratory tests, anesthesia and medicines (excluding take home drugs) when Hospital Confined.

3) Daily Intensive Care Unit/Cardiac Care Unit Expenses: the daily room rate when a Covered Person is Hospital confined in a bed in the Intensive Care Unit/Cardiac Care Unit and nursing services other than private duty nursing services.

4) Medical Emergency Care (room and supplies) expenses incurred within 72 hours of a Covered Accident and including the attending Physician’s charges, x-rays, laboratory procedures, use of the emergency room and supplies.

5) Outpatient surgery expenses, including Ambulatory Surgical Center.

6) Outpatient surgical room and supply expenses for use of the surgical facility.

7) Outpatient diagnostic x-rays, laboratory procedures and test expenses.

8) Physician non-surgical treatment/examination expenses (excluding medicines) including the Physician’s initial visit, each necessary follow-up visit and consultation visits when referred by the attending Physician.

9) Second surgical opinion expenses.

10) Physician surgical expenses. If an Injury requires multiple surgical procedures, we will pay 100% of the available benefit for the largest of the procedures performed, 50% of the available benefit for the second procedure and 25% of the available benefit for any additional eligible procedures.

11) Assistant Surgeon expenses when Medically Necessary.

12) Anesthesiologist expenses for pre-operative screening and administration of anesthesia during a surgical procedure whether on an inpatient or outpatient basis.

13) Outpatient laboratory test expenses.

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14) Physiotherapy (physical medicine) expenses on an inpatient or outpatient basis limited to one visit per day;

expenses include treatment and office visits connected with such treatment when prescribed by a Physician, including diathermy, ultrasonic, whirlpool, heat treatments, chiropractic, adjustments, manipulation, massage or any form of physical therapy.

15) Post surgical physical medicine expenses and office visits connected with such treatment when prescribed by a Physician.

16) Diagnostic imaging expenses including magnetic resonance imaging (MRI) and CAT scans.

17) Dental expenses including dental x-rays for the repair or treatment of each injured tooth that is whole sound and a natural tooth at the time of the Covered Accident.

18) Outpatient registered nurse services if ordered by a Physician.

19) Ambulance expenses for transportation from the Accident site to the Hospital.

20) Rehabilitative braces or appliances prescribed by a Physician. It must be durable medical equipment that is primarily and customarily used to serve a medical purpose and can withstand repeated use and generally is not useful to a person in the absence of injury. No benefits will be paid for rental charges in excess of the purchase price.

21) Prescription drug expenses prescribed by a Physician and administered on an outpatient basis.

22) Medical equipment rental expenses for a wheelchair or other medical equipment that has therapeutic value for the Covered Person. We will not cover computers, motor vehicles or modifications to a motor vehicle, ramps and installation costs.

23) Medical services and supplies for blood and blood transfusions; oxygen and its administration.

24) Artificial limbs, eyes and larynx for initial acquisition and fitting. We will not pay for repair or replacement of artificial limbs, eyes or larynx.

25) Heart and circulatory conditions: expenses for treatment of heat exhaustion, heart attack, stroke, burst aneurysm if the condition occurs during a Covered Accident.

26) Expanded medical benefit for sports conditions for treatment of bursitis, sprains, hernia, strains, muscle tears, tendonitis and repetitive motion injuries if these conditions are aggravated by participation in a Covered Activity.

27) Expenses due to an aggravation or re-injury of a prior Injury resulting in from a Covered Accident.

28) Charges for Emergency Care (as defined).

29) Charges incurred for Telehealth Service and Telemedicine Medical Service.

"Telehealth Service" means a health service other than a telemedicine medical service, delivered by a licensed or certified health professional acting within the scope of the health professional's license or certification who does not perform a telemedicine medical service that requires the use of advanced telecommunications technology, other than by telephone or facsimile, including:

a. Compressed digital interactive video, audio, or data transmission;

b. Clinical data transmission using computer imaging by way of still-image capture and store and forward; and

c. Other technology that facilitates access to health care services or medical specialty expertise.

"Telemedicine Medical Service" means a health care service initiated by a Physician or provided by a health professional acting under Physician delegation and supervision for purposes of patient assessment by a health professional, diagnosis or consultation by a Physician, treatment, or the transfer of medical data, that requires the use of advanced telecommunications technology, other than by telephone or facsimile, including:

a. Compressed digital interactive video, audio, or data transmission;

b. Clinical data transmission using computer imaging by way of still-image capture; and

c. Other technology that facilitates access to health care services or medical specialty expertise.

It also:

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a. means medical services delivered by telecommunications technologies to rural or underserved public not-for-profit health care facilities or primary health care facilities in collaboration with an academic health center and an associated teaching hospital or tertiary center or with another public not-for-profit health care facility; and

b. includes consultative services, diagnostic services, interactive video consultation, teleradiology, telepathology, and distance education for working health care professionals.

30) Charges incurred for Medically Necessary treatment, including cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and rehabilitation, neurobehavioral, neurophysiological, neuropsychological, and psychophysiological testing or treatment, neurofeedback therapy, remediation, post-acute transition services, or community reintegration services necessary as a result of and related to an acquired brain injury due to an Accident covered under the Policy.

“Acquired brain injury” means neurological insult to the brain, which is not hereditary, congenital, or degenerative. The injury to the brain has occurred after birth and results in a change in neuronal activity, which results in an impairment of physical functioning, sensory processing, cognition, or psychosocial behavior.

“Cognitive communication therapy” means services designed to address modalities of comprehension and expression, including understanding, reading, writing, and verbal expression of information.

“Cognitive rehabilitation therapy” means services designed to address therapeutic cognitive activities, based on an assessment and understanding of the individual’s brain-behavioral deficits.

“Community reintegration services” means services that facilitate the continuum of care as an affected individual transitions into the community.

“Neurobehavioral testing” means an evaluation of the history of neurological and psychiatric difficulty, current symptoms, current mental status, and premorbid history, including the identification of problematic behavior and the relationship between behavior and the variables that control behavior.

“Neurobehavioral treatment” means interventions that focus on behavior and the variables that control behavior.

“Neurocognitive rehabilitation” means services designed to assist cognitively impaired individuals to compensate for deficits in cognitive functioning by rebuilding cognitive skills and/or developing compensatory strategies and techniques.

“Neurocognitive therapy” means services designed to address neurological deficits in informational processing and to facilitate the development of higher level cognitive abilities.

“Neurofeedback therapy” means services that utilize operant conditioning learning procedure based on electroencephalography (EEG) parameters, and which are designed to result in improved mental performance and behavior, and stabilized mood.

“Neurophysiological testing” means an evaluation of the functions of the nervous system.

“Neurophysiological treatment” means interventions that focus on the functions of the nervous system.

“Neuropsychological testing” means the administering of a comprehensive battery of tests to evaluate neurocognitive, behavioral, and emotional strengths and weaknesses and their relationship to normal and abnormal central nervous system functioning.

“Neuropschological treatment” means interventions designed to improve or minimize deficits in behavioral and cognitive processes.

“Post-acute transition services” means services that facilitate the continuum of care beyond the initial neurological insult through rehabilitation and community reintegration.

“Psychophysiological testing” means an evaluation of the interrelationships between the nervous system and other bodily organs and behavior.

“Psychophysiological treatment” means interventions designed to alleviate or decrease abnormal physiological responses of the nervous system due to behavioral or emotional factors.

“Remediation” means the process(es) of restoring or improving a specific function.

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Terms of Payment for Accident Medical and Dental Expense Benefit

Full Excess:

If a Covered Person incurs Covered Expenses, We will pay the applicable benefit, subject to any applicable Deductible, Coinsurance Factor and Benefit Period shown on the Schedule of Benefits that are in excess of expenses payable by any other Health Care Plan, regardless of any Coordination of Benefits provision contained in such Health Care Plan. The first expense must be incurred within the Loss Period stated on the Schedule of Benefits. The Total Benefit Maximum payable and sub-limits under the Policy are shown on the Schedule of Benefits.

For the purposes of this provision, “Health Care Plan” means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under:

(1) group or blanket insurance, whether on an insured or self-funded basis;

(2) hospital or medical service organizations on a group basis;

(3) Health Maintenance Organizations on a group basis;

(4) group labor management plans;

(5) employee benefit organization plan;

(6) professional association plans on a group basis;

(7) any other group employee welfare benefit plan as defined in the Employee Retirement Income Security

Act of 1974 as amended; or

(8) automobile no-fault coverage (unless prohibited by law).

EXCLUSIONS

This Policy does not cover any loss resulting in whole or part from, or contributed to by, or as a natural or probable consequence of any of the following even if the immediate cause of the loss is an accidental bodily injury, unless otherwise covered under this policy by Additional Benefits:

• Suicide, intentional self-destruction, attempted intentional self-destruction or intentional self-inflicted Injury while sane or insane.

• War or any act of war, declared or undeclared.

• Sickness, disease or any bacterial infection, except one that results from an accidental cut or wound or pyogenic infections that result from accidental ingestion of contaminated substances.

• Intoxication or being under the influence of any drug or narcotic.

• Violation or in violation or attempt to violate any duly-enacted law or regulation, or commission or attempt to commit an assault or felony, or that occurs while engaged in an illegal occupation.

• Covered Expenses for which the Covered Person would not be responsible in the absence of this Policy.

• Injuries paid under Workers’ Compensation, Employer’s liability laws or similar occupational benefits or while engaging in activity for monetary gain from sources other than the Policyholder.

• Participation in any motorized race or speed contest.

• Injury caused by, contributed to or resulting from the Covered Person’s use of alcohol, illegal drugs or medicines that are not taken in the dosage or for the purpose as prescribed by the Covered Person’s Physician.

• Services or treatment rendered by a Physician, Nurse or any other person who is employed or retained by the policyholder; or an Immediate Family member of the Covered Person.

• Damage to or loss of dentures or bridges or damage to existing orthodontic equipment, except as specifically provided in this Policy.

• Loss resulting from participation in any activity not specifically covered by this Policy.

• Any treatment, service or supply not specifically covered by this Policy.

• Eyeglasses, contact lenses, hearing aids.

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• Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from:

While riding as a passenger in any aircraft not intended or licensed for the transportation of passengers; or While being used for any test or experimental purpose; or While piloting, operating, learning to operate or serving as a member of the crew thereof.

CLAIMS PROVISIONS

NOTICE OF CLAIM: Written notice of death or injury must be given to the Company within 30 days after a Covered Loss/Injury begins or as soon as reasonably possible. Notice can be given to the Company at BMI Benefits, 76 Main Street, P.O. Box 511, Matawan, NJ 07747, Attn: Claims Department. Notice should include the Covered Person’s name and address as well as this Policy Number. If written notice is not received within 30 days, the claim may be reduced or invalidated. However, the claim will not be reduced or invalidated if:

1) it can be shown that it was not possible within reason to submit notice within the 30 day period; and

2) it is further shown that notice was given as soon as possible.

CLAIM FORMS: When the Company receives a notice of claim, the Company will send forms for filing proof of loss. If claim forms are not sent within 15 days after receipt of such notice, Proof of Loss requirements stated below will be deemed to have been met if, within the Proof of Loss time period specified below, written proof of the nature and extent of the loss is submitted.

PROOF OF LOSS: Written proof of loss must be given to the Company within 180 days after the date of loss. If the proof of loss is not submitted within 180 day, the claim may be reduced or invalidated. However, the claim will not be reduced or invalidated if:

1) it can be shown that it was not possible within reason to submit notice within the 180 day period; and

2) it is further shown that notice was given as soon as possible, and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.

TIME OF PAYMENT OF CLAIMS: Benefits for loss covered by this Policy, other than benefits that require periodic payment, will be paid as soon as the Company receives proper written proof of such loss. Benefits for loss covered by this Policy that require periodic payment shall be paid monthly provided that the Company receives proper written proof of such loss.

PAYMENT OF CLAIMS: All benefits will be paid in United States currency. Loss of life benefits will be paid to the beneficiary as described in the Designation or Change of Beneficiary provision of this Policy entitled ‘General Policy Provisions’. To receive proceeds, a beneficiary must be living on the earlier of the following dates: the date the Company receives proof of the loss of life; or the 10th day after the death.

If the Covered Person dies, any unpaid accrued benefits will be payable according to the assignment on the claim, if any. If there is no valid assignment, unpaid accrued benefits will be payable in accordance with the beneficiary designation, if any, or to the Covered Person’s estate.

If any benefit becomes payable to the Covered Person’s estate, or to someone who is a minor or otherwise not competent to give a valid release, We may pay such benefit up to $1,000.00 to any relative by blood, or connection by marriage of the Covered Person or beneficiary who is deemed by Us to be equitably entitled to it.

Benefits will be payable to the Texas Department of Human Services if any of the following conditions exist:

1. The Covered Person or, if a minor, the Covered Person’s parent has executed an assignment of benefits by reason of making application for or receiving benefits for medical assistance under the Medical Assistance Act of 1967 of the State of Texas, as amended;

2. The minor Covered Person’s parent is:

a. A possessory conservator of said minor Covered Person under an order issued by a Texas court or is not entitled to possession or access to said minor Covered Person; and AH51051E TX 14 TX – College Sports Only Excess (1/12)

b. Required by court order or court approved agreement to pay child support; or

3. The Texas Department of Human Services is paying benefits on behalf of the minor Covered Person under

Chapter 31 or 32 of the Human Resources Code.

We must receive written notice of any of the above conditions and the assignment created by them by an attachment to the claim form originally submitted for benefits under the Policy.

Benefits for a minor may be paid on behalf of the minor to a person who is not the Covered Person if an order issued by a court of competent jurisdiction in Texas names such person the managing conservator of the minor.

Such benefits will be payable to the managing conservator provided the conservator has submitted:

1. Written notice to Us with the claim application that such person is the Covered Person’s managing conservator; and

2. A certified copy of a court order establishing the person as managing conservator or other evidence designed by rule of the State Board of Insurance that such person qualifies to be paid the benefits.

Such requirements shall not apply in the cases of any unpaid medical bill for which a valid assignment of benefits has been exercised or to claims submitted by the parent of a minor Covered Person where the parent has paid any portion of a medical bill that would be covered under the terms of the Policy.

Any payment made in good faith and compliance with Texas regulations regarding payment of benefits for medical services shall fully discharge Us to the extent of such payment.

PHYSICAL EXAMINATIONS AND AUTOPSY: We have the right to have a Physician of Our choice examine the Covered Person as often as is reasonably necessary. This section applies when a claim is pending or while benefits are being paid. We also have the right to request an autopsy in the case of death, unless the law forbids it.

We will pay the cost of the examination or autopsy.

RECOVERY OF OVERPAYMENT: If benefits are overpaid, or paid in error We have the right to recover the amount overpaid or paid in error by any of the following methods.

1) A request for lump sum payment of the amount overpaid or paid in error or

2) Reduction of any proceeds payable under this Policy by the amount overpaid or paid in error.

RIGHT OF RECOVERY: A Covered Person may incur charges due to an Injury for which benefits are paid by this Policy. The Injury may be caused by the act or omission of another person. If so, the Covered Person may have a claim against that other person for payment of expense-incurred charges. If Recovery under the claim is made, the Covered Person must repay Us the Recovery made from 1) the other person; or 2) the other person’s insurer.

Only the amount recovered for charges incurred will be subject to Refund. One-third of the Net Recovery will be deemed to be for such charges. However, in no case will the amount of Refund exceed the amount of benefits paid for the Injury under this Policy.

The right of Refund also applies when the Covered Person recovers under an uninsured or underinsured motorist plan.

“Recovery” means monies paid to the Covered Person through judgment, settlement or otherwise to compensate for all losses caused by the Injury.

“Net Recovery” means the Covered Person’s Recovery less attorney’s fees and court costs incurred in making the Recovery.

“Refund” means repayment to Us for benefits paid.

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SUBROGATION: The Policyholder is required to investigate and prosecute all valid claims that it may have against third parties arising out of any claim for which benefits were paid by this Policy. The Policyholder shall account to the Company for all amounts recovered. If the Policyholder fails to pursue any action against a third party and the Company has made benefit payments under this Policy, the Company will be subrogated to all of the Policyholder’s rights to make recoveries. However, the Company’s Subrogation right is secondary to the Policyholder’s right to be fully compensated for its damages. The Policyholder is required to cooperate fully and do all things necessary and required for the Company to pursue any action to recover against the third party; the scope of the Policyholder's cooperation shall include, without limitation, the execution of a Subrogation receipt or assignment in favor of the Company and the granting of authorization to the Company to commence litigation or other legal proceedings in the name of the Policyholder to seek recoveries from third parties. The Company agrees to pay its portion of the Policyholder’s attorneys’ fees or other costs associated with a claim or lawsuit to the extent that the Company recovers any portion of the benefits paid under this Policy pursuant to its Subrogation right.

GENERAL POLICY PROVISIONS

ENTIRE CONTRACT/CHANGES: This Policy, with the Policyholder’s Master Application and all endorsements, amendments and attached papers is the entire contract between the Policyholder and the Company.

Changes to this Policy may be made at any time by an endorsement or amendment and must be agreed upon, in writing, between the Policyholder and the Company. The Company may also, upon 31 days written notice to the Policyholder, change or modify the provisions of this Policy to comply with any applicable requirements of the Internal Revenue Service and/or any state or other federal law or regulation. No agent may change this Policy or waive any of its provisions.

TIME LIMIT ON CERTAIN DEFENSES: In the absence of fraud, all statements made by the Policyholder or by a Covered Person shall be deemed representations and not warranties. No such statement shall be used to contest this Policy or reduce benefits unless contained in a signed, written application, a copy of which has been provided to the person who made the statement, or to their beneficiary or representative. No such statement will be used to contest this Policy after this Policy has been in force for two years.

CLERICAL ERROR: Clerical error in keeping any records pertaining to the coverage, whether by the Policyholder or by the Company, will not invalidate coverage otherwise validly in force nor continue coverage otherwise validly terminated, provided such clerical error is not prejudicial to the Company and is rectified promptly upon discovery.

CONFORMITY WITH STATE STATUTES: Any provision of this Policy in conflict on its effective date with the laws of the state of Texas is amended to conform to the minimum requirements of such laws.

DESIGNATION OR CHANGE OF BENEFICIARY: Each Covered Person may designate a beneficiary to whom loss of life benefits are payable. The designation shall be as follows in descending order of preference:

1) Beneficiaries designated in writing by the Covered Person for this Policy on file with the Policyholder, if any, otherwise;

2) Beneficiaries as designated in writing for any group life insurance plan or its renewals in force for the

Policyholder, if any, otherwise;

3) In equal shares to the members of the first surviving class of those that follow, if any:

a) a Covered Person’s lawful spouse, if not legally separated or divorced, or Domestic Partner;

b) a Covered Person’s natural Child, adopted Child, foster Child, stepchild, or other Child for whom the

Covered Person has or had legal guardianship (proof will be required); or

c) a Covered Person’s parents, whether natural, step or adoptive; otherwise.

AH51051E TX 16 TX – College Sports Only Excess (1/12)

4) The estate of the Covered Person.

A Covered Person may change his/her beneficiary designation from time to time without the consent of the designated beneficiary by giving notice, in writing, to the Policyholder. When a request for designation or change is received by the Policyholder, it will take effect on the date of its execution, whether or not the Covered Person is living on the date it is received by the Policyholder. Any interest created by the request will be subject to any payment made or action taken before its receipt.

ASSIGNMENT: No assignment of interest in loss of life benefits shall be binding on the Company until the original or duplicate thereof is received by the Company. The Company assumes no responsibility for the validity of such assignment.

INSOLVENCY: The insolvency, bankruptcy, financial impairment, receivership, voluntary plan of arrangement with creditors, or dissolution of the Policyholder will not impose upon the Company any liability other than the liability defined in this Policy. The insolvency of the Policyholder will not make the Company liable to the creditors of the Policyholder, including Covered Persons under this Policy.

LEGAL ACTION: All Policy terms will be interpreted under the laws of the state in which this Policy was issued. No legal action may be brought to recover on this Policy within 60 days after written Proof of Loss has been furnished. No legal action may be brought after three (3) years from the time written Proof of Loss is required to be furnished.

MISSTATED DATA: The Company has relied upon the underwriting information provided by the Policyholder, its Third Party Administrator or other Agent in the issuance of this Policy. Should subsequent information become known which, if known prior to issuance of this Policy, would have affected the rates, Deductibles, terms or conditions for coverage, the Company will have the right to revise the rates, Deductibles, terms or conditions as of the Effective Date of issuance, by providing written notice to the Policyholder.

WAIVER: Failure of the Company to strictly enforce its rights under this Policy at any time or under any circumstance shall not constitute a waiver of such rights by the Company at any time under the same or different circumstances.

WORKERS’ COMPENSATION: This Policy is not in lieu of and does not affect any requirements for coverage by any Workers' Compensation Act or similar law.

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Urbandale, Iowa

Administrative Office: 2445 Kuser Road, Suite 201, Hamilton Square, NJ 08690 A Berkley Company

TEXAS NOTICE RIDER

This Rider is attached to and made a part of Policy Number ICS L00400772 001 issued to Angelo State University (the Policyholder).

The Policy is amended for Texas by adding the following:

IMPORTANT NOTICE AVISO IMPORTANTE

To obtain information or make a complaint: Para obtener informacion o para someter una queja:

You may call Berkley Life and Health Insurance Usted…