Fillable International Insurance Waiver Appeal Guidelines (Houston Community College)

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International Insurance Waiver Appeal Guidelines (Houston Community College)

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Rev. 08/2019 1 of 3
Houston Community College requires all students holding an F-1 visa to maintain health insurance coverage.
Students who submitted a waiver of the international health insurance and were denied based on the defined
criteria may appeal the denial by submitting this form along with an attached description of their current health
insurance plan and benefits to the International Insurance Waiver Committee for further review and
consideration.
Deadlines: all documents must be submitted in person or postmarked by the following
dates Fall semester – October 8, 2019
Spring semester – March 8, 2020
Summer semester – June 25, 2020 (only students whose initial semester of attendance is the
summer semester)
*Late submissions will NOT be accepted.
Complete the appeal process by submitting all of the following documents to the
HCC Risk Management Office on or before the required deadline:
1. International Insurance Waiver Appeal Form
2. Formal request for appeal in the form of a written/typed letter signed by the student stating the nature of
the request for appeal and the circumstances of the case.
3. A summary of benefits of the student’s current insurance plan from the insurance company.
4. A copy of the notification email of the denial of the insurance waiver from AHP.
Submit all the documen
ts to the HCC Risk Management Office:
In person:
Monday-Thursday: 9:00AM - 4:00PM
Friday: 9:00AM - 1:00PM
3100 Main St. (1st. floor)
Houston, TX 77002
All requests will
be audited. All decisions made by the International Insurance Waiver Committee are final.
Those failing audit will be enrolled in the HCC sponsored international insurance plan.
Appeals will not be accepted
if:
1. The waiver was denied because you missed the waiver submission deadline.
2. The waiver was denied because you have a private/individual insurance plan.
3. The appeal applies to a waiver submitted for a previous school term.
(appeals will be considered for the current term only)
The International Insurance Waiver Committee will email the student with the final decision of the appeal to the
email address on
the International Insurance Waiver Appeal Form on or before the following dates:
Fall semester – October 21, 2019
Spring semester – March 22, 2020
Summer semester – July 10, 2020
International Insurance Waiver Appeal Guidelines
By Mail:
Houston Community College Risk
Management Office: MC-1119
P.O. Box 667517
Houston,
TX 77266
Rev. 08/2019 2 of 3
1. Term
___ Fall year__________ ___ Spring year__________ ___ Summer year__________
2. Student
Information
_____________________________
___________________________ ___________________________
Family (Last) Name First Name Middle Name
_____________________________ _________
__________________ ___________________________
Date of Birth (MM/DD/YY) US Phone Number Email Address
3. Current Insurance Information
____________________________________ _____________________
__________________________
Name of Insurance Company US Phone Number Email Address
_______________________________________________________________________________________
Address of Insurance Company
_____________________________ ___________________________ ___________________________
Insured’s Name Date of Birth
(MM/DD/YY) Insured’s ID Number
_____________ ________________________ _____________________ _______________________
Group Number Policy Number Effective Date
(MM/DD/YY) Expiration Date (MM/DD/YY)
4. Reason for denial (found on notification email from AIG)
___ Coverag
e dates do not include the entire coverage period you are waiving.
___ Medical benefits are not at least $50,000 USD for each accident or sickness.
___ Policy has an annual deductible of more than $500.00 USD;
(a Health Care spending account is not acceptable as an alternative)
___ The minimum paid for covered benefits is greater than 75%.
___ Repatriation of Mortal Remains is less than $7,500.00 USD.
___ Medical Evacuation is less than $10,000 USD.
___ Policy excludes or unreasonably limits coverage for activities essential for students;
(such as a $10,000 limit on motor vehicle accidents, a 13 week benefit period)
___ Other: ________________________________________________________________________
_______________________________ _________________________________ __________________
Student Name (please print) Student Signature Date (MM/DD/YY)
International Insurance Waiver Appeal Form
HCC ID #: _______________________
Waiver Confirmation #: _______________________
(found on the notification email from AHP)
Committee Authorization:
For International Insurance Waiver Committee Office Use Only:
Waiver Appeal: ___ Approved ___ Not Approved
Reason ______________________________________________________________________________
_____________________ _______________________ ______________________ ___________
Print Name Print Title Signature Date
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Completed 6 October 2020

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