Soccer Accident Insurance Form - SAI
Soccer Accident Insurance-Updated benefit information effective July 1, 2017
AYSO purchases Soccer Accident Insurance (“SAI”), which pays excess medical costs up to $50,000 maximum per accident to an insured person for accidental bodily injuries incurred as a direct result of participation in a covered activity subject to the policy terms, conditions and exclusions. Eligibility for benefits is 52 weeks from the policy effective date or the date of a covered accident. For a more detailed explanation of the plan see the SAI Brochure. Accident Medical Expense Benefits are only payable:
- For usual and customary charges incurred after the deductible has been met;
- For those medically necessary covered expenses that the covered person receives;
- First medical or dental expense must be incurred within 90 days of covered accident;
- proof of loss must be filed within 90 days;
- each claim is subject to a $1000 Deductible; and 20% member Coinsurance;
Claims will require:
- Copies of primary Explanation of Benefits (EOB)
- Copies of itemized insurance billing forms – UB04 or CMS1500
Primary Insurance: If there is no other insurance available to the registered member, the medical benefit will be processed on a primary basis subject to Usual and Customary rates, and the policy terms, conditions and exclusions.
MAXIMUM BENEFITS PAYABLE: (subject to policy terms, conditions & limits)
- $50,000 maximum excess medical costs
- $15,000 for Accidental Death & Dismemberment
- $10,000 for Dental Benefit for injuries to sound natural teeth
- $10,000 for Orthopedic Benefit
- $1,000 Physical Therapy; $100 per day up to 10 days
All AYSO, currently registered*, members (players, coaches, managers, team workers, referees, officials and volunteer workers) are “Covered Persons” for accidental bodily injury while participating in the following covered activities:
- Team practice sessions, scheduled games, tournaments, or other sponsored activities (meetings, banquets, fundraisers) provided they are under the direct supervision of an AYSO registered volunteer.
- Travel of covered members to and from a sponsored activity such as practice sessions, games, tournaments, or AYSO sanctioned activities, provided that players are traveling as a team and a licensed adult driver operates the vehicle.
* Registration requirements will be verified before any benefits are paid.