Middlebury, Vermont

Policy Number CUH200765

• Mandatory Student Accident Only Insurance Plan

• Student Accident Only Insurance Plan Summer Coverage

• Voluntary Student Accident & Sickness Insurance Plan

• Voluntary Supplemental Student Accident & Sickness Insurance Plan

• Mandatory Student Accident Only Insurance Plan

• Student Accident Only Insurance Plan- Summer Coverage

• Voluntary Student Accident & Sickness Insurance Plan

• Voluntary Supplemental Student Accident & Sickness Insurance Plan

• Inpatient Hospital Expense Benefits

• Surgical Expense Benefits (Inpatient or Outpatient)

• Outpatient Expense Benefits

• Mental and Nervous Conditions and Alcohol & Drug Abuse Expense Benefits

• Additional Benefits

• State Mandated Benefits

This brochure describes the insurance coverage under the Middlebury College Student Insurance Plans. This plan is underwritten by Combined Insurance Company of America, serviced by Koster Insurance Agency and claims are administered by Klais & Company, Inc. The exact provisions governing this Student Accident and Sickness Plan are contained in the Master Policy which will be issued to the College.

All undergraduate and graduate students enrolled as full-time students of Middlebury College are eligible to enroll in the Student Accident & Sickness Insurance Plan.

• Mandatory Student Accident Only Insurance Plan

All undergraduate and graduate students enrolled at Middlebury College are automatically enrolled in the Mandatory Student Accident Only Insurance Plan. The Mandatory Student Accident Only Insurance Plan provides coverage for Covered Medical Expenses incurred as a result of an Accident sustained during the academic year, 9/1/07-5/31/08.

• Student Accident Only Insurance Plan –

Summer Coverage

Students who are enrolled for classes during the Summer Term will be automatically enrolled in the Mandatory Student Accident Only Insurance Plan for the Summer Term, 6/1/08-9/1/08. However, students not taking summer classes will not be automatically enrolled, but are eligible to enroll on a voluntary basis. Students should consider purchasing summer coverage in order to maintain continuous coverage in the Student Accident Only Insurance Plan.

• Voluntary Student Accident & Sickness

Insurance Plan

All undergraduate and graduate students enrolled in the Mandatory Student Accident Only Insurance Plan are eligible to enroll in the Student Accident & Sickness Insurance Plan on a voluntary basis. The Voluntary Student Accident & Sickness Insurance Plan combines coverage for Covered Expenses incurred as a result of a Sickness with the coverage available under the Mandatory Student Accident Only Insurance Plan. Students who elect to purchase this Plan will be covered by the Voluntary Student Accident & Sickness Insurance Plan for the entire policy year, 9/1/07 to 9/1/08.

• Voluntary Supplemental Accident & Sickness

Insurance Plan

Students who enroll in the Voluntary Student Accident & Sickness Insurance Plan are also eligible to enroll in the Voluntary Supplemental Student Accident & Sickness Insurance Plan that increases the Per Condition Aggregate Maximum Benefit and provides coverage for emergency medical evacuation and repatriation of remains.

The Mandatory Accident Only Insurance Plan for the Academic year term is effective at 12:01 a.m. on September 1, 2007 and terminates at 12:01 a.m. on May 31, 2008. Spring term coverage is effective at 12:01 a.m. on February 1, 2008 and terminates at 12:01 a.m. on May 31, 2008. The Student Accident Only Insurance Plan-Summer Coverage is effective at 12:01 a.m. on June 1, 2008 and terminates at 12:01 a.m. on September 1, 2008.

The Voluntary Accident & Sickness Insurance Plan and the Voluntary Supplemental Accident & Sickness Plan are effective at 12:01 a.m. on September 1, 2007 and terminate at 12:01 a.m. on September 1, 2008, for annual coverage. Spring term coverage is effective at 12:01 a.m. on February 1, 2008 and terminates at 12:01 a.m. on September 1, 2008. Enrollment in the Voluntary Accident & Sickness Insurance Plan extends the Mandatory Accident Only Insurance Plan through September 1, 2008.

Voluntary for Students not taking Summer Classes

If an Insured Student withdraws from the university within the first 31 days of the first semester, and has not yet submitted a claim, he or she will receive a full refund of the insurance premium. If an Insured Student withdraws from the university after 31 days of the first semester, his or her coverage will remain in effect until the end of the term for which he or she was charged premium. Those Insured Students withdrawing from school to enter military service will be entitled to a pro-rata refund of premium upon written request of the withdrawal from school, and coverage will end as of the date of such entry.

Middlebury College offers a wide range of health services through the Parton Health Center and the Center for Counseling and Human Relations, most of which are included in the cost of a student's comprehensive fee (which is separate from the insurance plan cost). During the academic year The Health Center is staffed 24-hours-a-day with a Registered Nurse. Appointments are available during regular business hours with a Physician, Nurse Practitioners and Registered Nurses. The services provided at the Health Center include but are not limited to:

• acute care outpatient clinic

• inpatient/overnight care

• allergy shots

• immunizations

• men's and women's health care including contraceptive management

• sexually transmitted infection testing and sexuality counseling

• comprehensive travel clinic

• limited laboratory services

• a wide range of over-the-counter medications

• referrals to appropriate local practitioners.

The Center for Counseling and Human Relations provides psychological and nutritional counseling. Three counselors provide short-term counseling, crisis intervention, educational and mental health programs, assessments and referrals to other professional therapists in the area. Students may be expected to pay for psychiatric assessment and follow-up psychiatric treatment. Zug Sports Medicine Center provides athletic training and sports medicine services to official team roster members of intercollegiate teams and club rugby and crew. For a complete list of services offered by Parton Health Center, the Center for Counseling and Human Relations and Zug Sports Medicine Center please see each web site accessed from Middlebury College's Home Page.

There is no charge for health center visits and overnight stays, visits to the Center for Counseling and Human Relations, Zug Sports Medicine Center or initial nutritionist evaluations. Students will be charged through the Health Center for certain lab tests, specifically STD and HIV testing, some vaccines and some medical supplies.

The discount vision plan is available through EyeMed, The Eye Care Plan of America. EyeMed's provider network consists of over 9,000 independent providers and retail stores nationwide, including LensCrafters. This is not an insurance plan; there is no waiting period. You will receive a separate EyeMed ID card and you can take advantage of the savings through EyeMed immediately upon receipt of your EyeMed plan ID card. You can purchase prescription eyeglasses, conventional contact lenses or even non-prescription sunglasses at savings between 15% and 50% off regular retail pricing. In addition, you can receive discounts from 5% to 15% off laser correction surgery by some of the nation's most highly qualified laser correction surgeons. To locate a participating provider, you can call 800-8EYEMED or go online at www.enrollwitheyemed.com. This Plan is not underwritten by Combined Insurance Company of America.

The Middlebury College Insurance Plans provide access to hospitals and health care Network Providers locally through the Health Care Value Management (HCVM) Preferred Provider Network in the New England states, and nationally through the CCN Preferred Provider Network. When Insured Students use Network Providers, out of pocket expenses will be less because any applicable student coinsurance is based on negotiated preferred fees or the Preferred Allowance. Students should be aware that Network Hospitals may be staffed with Non-Network Providers. Receiving services or care from a Non-Network Provider at a Network Hospital means that those charges will not be paid at the Network Provider level of benefits. It is important that the Insured Student verify that his or her Doctors are Network Providers when calling for an appointment or at the time of service. The most efficient and accurate way to identify Network Providers in the HCVM network is by contacting HCVM at www.HCVM.com or calling 1-800-922-4286, or by contacting CCN at www.ccnusa.com or calling 1-800-247-2898.

When, by reason of Accident, an Insured Person incurs expenses for Hospital, surgical or medical treatment, services or supplies, We will pay 100% of the Covered Expenses incurred up to a Per Condition Aggregate Maximum benefit of $5,000. In addition, when an Insured Person incurs expenses for dental treatment for Injury to sound natural teeth, We will pay 100% of the Covered Charges incurred up to a maximum of $1,000 per policy year.

When, by reason of Accident, and Insured Person incurs expenses for Hospital, surgical or medical treatment, services supplies, We will pay 100% of the Covered Expenses incurred up to a Per Condition Aggregate Maximum benefit of $2,000. In addition, when an Insured Person incurs expenses for dental treatment for Injury to sound natural teeth, We will pay 100% of the Covered Charges incurred up to a maximum of $1,000 per policy year.

The Voluntary Student Accident & Sickness Insurance Plan maintains the coverage available through the Student Accident Only Insurance Plan and provides additional coverage for Covered Expenses incurred as a result of a Sickness. Payment will be made as allocated on the following Schedule of Medical Benefits for Covered Expenses incurred for an Accident or Sickness while insured under the Voluntary Student Accident & Sickness Insurance Plan up to the Per Condition Aggregate Maximum of $25,000.

Only students enrolled in the Voluntary Student Accident & Sickness Insurance Plan are eligible to purchase the Voluntary Supplemental Student Accident & Sickness Insurance Plan that provides additional coverage. This Plan provides coverage after the $25,000 Per Condition Aggregate Maximum has been met under the Voluntary Student Accident & Sickness Insurance Plan. The Voluntary Supplemental Student Accident & Sickness Insurance Plan increases the Per Condition Aggregate Maximum to $50,000. The maximum benefit that will be provided for one covered Injury or Sickness is $50,000. Benefit limitations are the same as defined under the Voluntary Student Accident & Sickness Insurance Plan, which means that those benefits that have individual maximum amounts payable under the Voluntary Student Accident & Sickness Insurance Plan will not be increased under the Voluntary Supplemental Student Accident & Sickness Insurance Plan. The Voluntary Supplemental Student Accident & Sickness Insurance Plan also includes the following Plan enhancements:

° EMERGENCY MEDICAL EVACUATION

EXPENSE BENEFIT

This benefit applies only to Domestic Students while Studying Abroad and International Students. This benefit will pay benefits for the Covered Percentage of the Covered Expenses incurred, if an Injury or Sickness results in the Emergency Medical Evacuation of the Insured Person.

° REPATRIATION OF BODY REMAINS

EXPENSE BENEFIT

This benefit applies only to Domestic Students while Studying Abroad and International Students. In the event of the death of an Insured Person, We will pay the actual charges for the Covered Expenses for the preparation and transportation of the Insured Person's remains to his or her Home Country or home residence. This will be done in accord with all legal requirements in effect at the time the body remains are to be returned to his or her Home Country. The death must occur while the person is insured for this benefit.

° INTERNATIONAL ASSISTANCE PROGRAM

The International Assistance Program (IAP) is included in the Student Insurance Plan that provides access to a 24-hour worldwide assistance network, On Call International, for emergency assistance anywhere in the world. Simply call the assistance center collect. The multilingual staff will answer your call and immediately provide reliable, professional and thorough assistance. The following services are included in this Plan:

1. Referral to the nearest, most appropriate medical facility, and/or Provider.

2. Medical monitoring by board certified emergency physicians in the United States.

3. Urgent message relay between family, friends, personal physician, school, and Insured.

4. Guarantee of payment to Provider and assistance in coordinating insurance benefits.

5. Arranging and coordinating emergency medical evacuations and repatriation of remains.

6. Emergency travel arrangements for disrupted travel as the consequence of a medical emergency.

7. Referral to legal assistance.

8. Assistance in locating lost or stolen items including lost ticket application processing. Contact On Call International for any of these services:

Toll Free from U.S. and Canada:

1-800-850-4556

Dial Direct or Call Collect Worldwide:

1-603-898-9159 or

Contact our website:

www.oncallinternational.com

Benefits under the Voluntary Student Accident and Sickness Insurance Planare provided in the schedule below with the benefits available described in the appropriate column. Treatment of an Injury must commence within 60 days of the date of Injury and expense must be incurred within the policy term. Sickness Expenses must be incurred during the term of the policy. Network Providersare the Physicians, Hospital and other health care providers who have contracted to provide specific medical care at Preferred Allowance. Preferred Allowancemeans the amount a Preferred Provider will accept as payment for Covered Medical Expenses. Non-Networkproviders have not agreed to any prearranged fee schedules. When Insured Students use Network Providers,Out-Of-Pocket expenses will be less because applicable student coinsurance is based on negotiated preferred fees or the Preferred Allowance.

• Hospital Room and Board Expense

When, by reason of Injury or Sickness an Insured Person requires Hospital Confinement, We will pay the Covered Percentage of Covered Charges incurred as outlined in the Schedule of Benefits. Covered Charges include: Hospital room and board for a semiprivate room containing two or more beds including meals and special diets incurred for the period of such Hospital Confinement. Coverage includes a bed in a newborn nursery, special care, or intensive care unit.

• Hospital Miscellaneous Expense

When, by reason of Injury or Sickness an Insured Person incurs expenses during a Hospital Confinement or for a Surgical Procedure performed on an Outpatient basis, We will pay the Covered Percentage of Covered Charges incurred as outlined in the Schedule of Benefits. Such Covered Charges include: anesthesia, anesthesia supplies and services; operating, delivery and treatment rooms and equipment; diagnostic X-ray and laboratory tests; lab studies; oxygen tent; blood and blood services; prescribed drugs and medicines; medical and surgical dressings, supplies, casts and splints; radiation therapy, intravenous chemotherapy, kidney dialysis, and inhalation therapy; intravenous injections and solutions, and their administration; physical and occupational therapy; and other necessary and prescribed hospital expenses, except personal service.

• In Hospital Doctor's Fees And Medical Expense

When, by reason of Injury or Sickness an Insured Person who is confined as a resident bed-patient in a Hospital, requires the services of a Doctor who may or may not have performed surgery on them Insured Person, We will pay the Covered Percentageof the Covered Charges incurred for such services as outlined in the Schedule of Benefits. The following medical services performed by a Doctor are covered on inpatient basis: (a) one Doctor visit per day; (b) constant care and treatment while an Insured Person is confined in an intensive care unit; (c) care by two or more Doctors during one Hospital stay when the Insured Person's condition requires the skill of separate Doctors.

• Licensed Nurse Expense

When, by reason of Injury or Sickness an Insured Person requires service of a licensed nurse or licensed practical nurse during a Hospital Confinement, We will pay the Covered Percentage of the Covered Charge incurred for such services as outlined in the Schedule of Benefits.

• Inpatient Consultant Expense

When, by reason of Injury or Sickness an Insured Person requires services of a Consultant or Specialist when they are deemed necessary and ordered by an attending Doctor for the purpose of confirming or determining a diagnosis, We will pay the Covered Percentage of the Covered Charge incurred for such services as outlined in the Schedule of Benefits.

• Surgical Expense

When, by reason of Injury or Sickness an Insured Person requires surgery on an inpatient or outpatient basis, We will pay the Covered Percentage of Covered Charges incurred as outlined in the Schedule of Benefits.

• Assistant Surgeon Expense/Anesthetist Expense

When, by reason of Injury or Sickness an Insured Person requires services of an anesthetist and/or assistant surgeon in connection with an operation, We will pay the Covered Percentage of Covered Charges incurred as outlined in the Schedule of Benefits.

• Outpatient Consultant Expense

When, by reason of Injury or Sickness an Insured Person requires the services of a Consultant or Specialist when they are deemed necessary and ordered by an attending Doctor for the purpose of confirming or determining a diagnosis, We will pay the Covered Percentage of Covered Charges incurred as outlined in the Schedule of Benefits.

• Outpatient Expense

When, by reason of Injury or Sickness an Insured Person incurs expenses for outpatient services, We will pay the Covered Percentage of Covered Charges incurred as outlined in the Schedule of Benefits. The following medical services are covered on an outpatient basis: (a) a Doctor's office visit while not Hospital Confined; (b) a Hospital outpatient department or emergency room; (c) diagnostic xray and laboratory testing; (d) radiological lab or other similar facility licensed by the state; (e) an Ambulatory Surgical Center for Covered Surgery; (f) blood and blood services, if provided and billed by a Hospital or other facility; (g) radiation therapy; (h) intravenous chemotherapy; (i) kidney dialysis; (j) inhalation therapy; (k) surgical dressings, splints, casts, and other devices used to correct fractures and dislocations; (l) speech therapy by a licensed speech therapist to restore speech loss or correct speech impairment after corrective surgery, or following an Injury for Sickness other than a mental or learning disorder. Speech therapy must be in keeping with a Doctor's written order for type, frequency, and duration; (m) shots and injections when received in the Doctor's office; (n) allergy testing.

• Physical Therapy Expense, including

Chiropractic Care

When, by reason of Injury or Sickness an Insured Person incurs expenses for Chiropractic Services and/or Physical Therapy, We will pay the Covered Percentage of the Covered Charge incurred for such services as outlined in the Schedule of Benefits.

When the Insured Person requires Hospital Confinement for treatment of a Mental or Nervous Condition, We will pay the Covered Percentage of the Covered Charges incurred for such Hospital Confinement on the same basis as any other Sickness as outlined in the Schedule of Benefits. Such confinement must be in a licensed or certified facility, including Hospitals.

When the Insured Person is confined as an inpatient in: (i) a Hospital; or (ii) a Detoxification Facility for the treatment of alcoholism, Alcohol Abuse, Drug Abuse, or drug dependency, We will pay the Covered Percentage of the Covered Charges incurred for such Hospital Confinement on the same basis as any other Sickness as described in the Schedule of Benefits. Such confinement must be in a licensed or certified facility, including Hospitals.

We will pay the Covered Percentage of the Covered Charges incurred as shown in the Schedule of Benefits. The Mental and Nervous Condition must, in the professional judgment of health care providers, be treatable, and the treatment must be Medically Necessary. Outpatient Treatment and Doctor services include charges made by an outpatient treatment department of a Hospital or community mental health facility or charges for services rendered in a Doctor's office. Treatment may be provided by any properly licensed Doctor, psychologist or other provider as required by law.

We will pay the Covered Percentage of the Covered Charges incurred as shown in the Schedule of Benefits for the treatment of alcoholism, Alcohol Abuse, Drug Abuse, or drug dependency. Outpatient Treatment and Doctor services include charges for services rendered in a Doctor's office or by an outpatient treatment department of a Hospital, community mental health facility or alcoholism treatment facility, so long as the Hospital, community mental health facility or alcoholism treatment facility is approved by the Joint Commission on the Accreditation of Hospitals or certified by the Department of Health. The services must be legally performed by or under the clinical supervision of a licensed Doctor or a licensed psychologist who certifies [every three months] that the Insured Person needs to continue such treatment.

• Accidental Dental Expense

We will pay 100% of Covered Charges incurred for dental treatment as a result of accidental Injury to sound natural teeth, up to a maximum of $1,000 per policy year.

• Sickness Dental Expense

If an Insured Person requires the services of a Doctor for the removal of impacted wisdom teeth or dental abscesses, We will pay the Covered Charges incurred up to a maximum of $50.00 per tooth.

• Ambulance Expense

When, by reason of Injury or Sickness, an Insured Person requires the use of a community or Hospital ambulance in a Medical Emergency, We will pay 100% of the Actual Expense up to a maximum of $200.00. Ambulance Services is transportation by a vehicle designed, equipped and used only to transport the sick and injured from home, scene of accident or Medical Emergency to a Hospital or between Hospitals. Surface trips must be to the closest local facility that can provide the covered service appropriate to the condition. If there is no such facility available, coverage is for trips to the closest facility outside the local area. Air transportation is covered when Medically Necessary because of life threatening Injury or Sickness. Air ambulance is air transportation by a vehicle designed, equipped and used only to transport the sick and injured to and from a Hospital for inpatient care.

• Prescription Drug Expense Benefit

The outpatient prescription drug benefit is available through the Medco Health Pharmacy Network. The Medco Health Pharmacy Network includes national pharmacy chains, CVS, Walgreens, Brooks and local independent pharmacies, such as Kinney's Drugs. After a per prescription copayment of $10.00 for a 30 day supply of a generic drug or a per prescription copayment of $20.00 for a 30 day supply of a brand name drug, the Expenses incurred for the cost of prescription drugs will be reimbursed at 100%, up to a maximum of $750.00 per policy year. Insured Persons will be given an ID card to show to the pharmacy as proof of coverage. If a prescription needs to be filled prior to receiving an ID card, reimbursement will be made upon submitting a completed Rx claim form (claim forms can be obtained from Koster Insurance Agency). A listing of Medco Health Pharmacies is available by calling 1-800-711-0917 or by viewing www.MedcoHealth.com. Not all medications are covered. (See Exclusion Section).

• Maternity Expense

We will pay benefits for an Insured Person's Covered Charges for maternity care, including Hospital, surgical and medical care. We cover charges for a minimum of 48 hours of inpatient care following an uncomplicated vaginal delivery and a minimum of 96 hours of inpatient care following an uncomplicated cesarean section for a mother and her newborn child in a health care facility, unless the attending Doctor in consultation with the mother, makes a decision for an earlier discharge from the Hospital. For a mother and newborn child who remain in the Hospital for the minimum length of time stated above, We will pay for one home health care visit if prescribed by the attending Doctor. For a mother and newborn child who have a shorter Hospital stay, We will pay for one home visit scheduled within 24 hours after Hospital discharge; and an additional home visit if prescribed by an attending provider. Newborn Infant Care is covered when the infant is confined in the Hospital and has received continuous Hospital care from the moment of birth. This includes: (a) nursery charges; (b) charges for routine Doctor's examinations and tests; and (c) charges for routine procedures. This benefit does not include circumcision. This benefit also includes the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities of newborn children covered from birth. Covered services may be provided by a certified nurse-midwife under qualified medical direction if he or she is affiliated with or practicing in conjunction with a licensed facility. We cover such charges the same way We treat Covered Charges for any other Sickness.

• Diabetes Treatment Expense

We will pay the Covered Percentage of the Covered Charges incurred by the Insured Person for the equipment, supplies and outpatient selfmanagement training and education, including medical nutrition therapy, for the treatment of insulin dependent diabetes, insulin using diabetes, gestational diabetes and noninsulin using diabetes if prescribed by a health care professional legally authorized to prescribe such items under law. Diabetes outpatient self-management training and education covered by this benefit shall be provided by a certified, registered or licensed health care professional with specialized training in the education and management of diabetes.

Pre-existing Condition is a Sickness, Injury, or related condition which was contracted or which manifested itself, or for which a licensed Doctor was consulted; or for which treatment or medication was prescribed within six (6) months prior to the Effective Date of the insured Person's coverage under this Policy. If the Insured Person has a lapse in coverage, the Pre-existing Condition Waiting Period will have to be satisfied again. The Pre-existing Condition Waiting Period is six (6) months. If an Insured Person receives treatment or service for a Pre-existing Condition the Company will pay on the same basis of policy benefits and benefit limits that apply to any other covered sickness not to exceed an aggregate maximum payment of $2,500 for any one sickness or injury. Expenses in excess of $2,500 for an Insured Person's Pre-existing Condition will not be covered until the Preexisting Condition waiting period is satisfied. We will not pay any additional benefits for such condition until the day after a twelve (12) consecutive month period has passed from the Insured Person's effective date.

This Policy may be replacing a Prior Plan with another insurer. Prior Planmeans the Student Health Insurance policy or policies issued to the Policyholder immediately before the current Policy. Injury or Sickness shall include an Injury sustained, or a Sickness first manifesting itself, while the Insured Person is continuously insured under the Prior Plan and became insured under this Policy without a break in coverage. But no benefits shall be payable for such Injury or Sickness to the extent that such benefits are payable under the Prior Plan for the same expenses. This will apply even though the Prior Plan provided that it will not duplicate the benefits under another Policy. Also, the total amount of benefits payable for such Injury or Sickness under this Policy and the Prior Plan cannot exceed the Per Condition Aggregate Maximum. Nothing contained herein shall be held to vary, alter, waive, or extend any of the provisions, exclusions, and other terms of this Policy, except as provided above.

This Plan does not cover nor provide benefits for:

1. Services normally provided without charge by the Policyholder's student health service center, infirmary, or Hospital, or by Health Care Providers employed by the Policyholder;

2. Expense incurred for eye examinations or prescriptions, eyeglasses, and contact lenses (except for sclera shells which are intended for use of corneal bandages), eye refractions, vision therapy, multiphasic testing, or lasix or other vision procedures except as required for repair caused by a covered Injury;

3. Expense incurred as the result of dental treatment, except as provided in the Sickness Dental Expense Benefit, if included in this Policy. This exclusion does not apply to treatment resulting from Injury to sound natural teeth;

4. Cosmetic surgery, except as the result of covered Injury occurring while this Policy is in force as to the Insured Person. This exclusion shall also not apply to cosmetic surgery, which is reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other disease of the involved body part, and reconstructive surgery because of congenital disease;

5. Injury due to participation in a riot;

6. Charges for treatment of any Injury or Sickness due to an Insured Person's participation in a felony;

7. Injury or Sickness resulting from declared or undeclared war; or any act thereof;

8. Accident occurring in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare paying passenger in an aircraft operated by a scheduled airline maintaining regular published schedules on a regularly established route;

9. Illness, Accident, treatment or medical condition arising out of hang-gliding, skydiving, glider flying, parasailing, sail planing, bungee jumping, racing or speed contests, skin diving, parachuting or bungicord jumping;

10. Injury or Sickness for which benefits are paid under any Workers' Compensation or Occupational Disease Law;

11. Injury resulting from motor vehicle accident to the extent that benefits are payable under any automobile medical expense insurance or automobile no-fault plans;

12. Illness, Accident, treatment or medical condition arising out of the play or practice of or traveling in conjunction with intercollegiate sports, in excess of $5,000;

13. Services not Medically Necessary;

14. For services or supplies rendered by a close relative of the Insured Person. By "close relative" We mean an Insured Person's spouse, children, parents, brothers and sisters;

15. Expense covered by any other valid and collectible medical, health or accident insurance;

16. Expense incurred after the date insurance terminates for an Insured Person except as may be specifically provided in the Extension of Benefits Provision, when applicable;

17. Services incurred prior to the Insured Person's Effective Date or during Hospital Confinement in one or more facilities, which began prior to the Insured Person's Effective Date;

18. An amount of a charge in excess of the Reasonable and Customary Expense;

19. Expense incurred for treatment of temporomandibular joint dysfunction and associated myofacial pain;

20. Expenses incurred for any experimental drug or drug combination which the Federal Food and Drug Administration (FDA) has not approved for any indication, or for any drug which the FDA has determined to be contraindicated for a particular condition;

21. Pre-existing Conditions as defined in this Policy;

22. Injury sustained or Sickness contracted while in service of the Armed Forces of any country, except as specifically provided. Upon the Insured Person entering the Armed Forces of any country, We will refund the unearned pro-rata premium to such Insured Person;

23. Personal hygiene/convenience items; telephone consultations, missed appointments, photocopies or medical records, or completion of claim forms; expenses incurred for custodial care or services not needed to diagnose or treat an Injury or Sickness, including but not limited to services related to the activities of daily living;

24. Treatment provided in a governmental Hospital unless there is a legal obligation to pay such charges in the absence of insurance;

25. Elective Treatment or elective surgery, except as specifically provided;

26. Treatment of mental or nervous disorders except as specifically provided;

27. Treatment of alcohol and substance abuse except as specifically provided;

28. Expenses incurred in connection with a voluntary sterilization procedure or any sterilization reversal process;

29. Treatment of obesity, including any care which is primarily dieting or exercise for weight loss, except for surgical treatment of morbid obesity;

30. Expenses incurred for transsexual surgery or any treatment leading to or in connection with transsexual surgery;

31. Expenses incurred for allergy treatment;

32. Preventative medicines, serums, immunizations, or vaccines, except insulin and as specifically provided;

33. Expense incurred for: tubal ligation; vasectomy; breast implants; breast reduction; sexual reassignment surgery; impotence (organic or otherwise); non-cystic acne; non-prescription birth control; submucus resection and/or other surgical correction for deviated nasal septum, other than for required treatment of acute purulent sinusitis; circumcision; gynecomastia; hirsutism;

34. Expense incurred for: topical acne treatments, moles, non-malignant warts or lesions, fertility medication; legend vitamins or food supplements; smoking deterrents; immunization agents; biological sera; drugs to promote or stimulate hair growth; experimental drugs; drugs dispensed in a rest home or hospital, except as provided under the Hospital Expense Benefit;

35. Routine periodical physical examinations and routine chest x-rays,except as specifically provided.

No benefit under this Policy is payable for any Expense incurred for Injury or Sickness which is paid or payable by: (1) other valid and collectible insurance; or (2) under an automobile insurance policy. Covered Medical Expenses exclude amounts not covered by the primary carrier due to penalties imposed on the Insured Person for failing to comply with policy provisions or requirements.

Insured Students who have been enrolled for at least six (6) months under the Student Accident and Sickness Insurance Plan, and who become ineligible for coverage due to leaving the school for graduation, reduction in credit hours, or for other purposes, may continue coverage for up to 9 months from the date of ineligibility by enrolling in a Continuation Plan. This Plan has a separate benefit and rate structure. Interested Persons need to enroll and submit payment within 15 days from their date of ineligibility. Please call Koster Insurance at (800) 457-5599 or email Studentcare@Kosterins.com for more information.

If an Insured Person is confined to a Hospital on the date his or her insurance terminates, charges incurred during the continuation of that Hospital Confinement shall also be included in the term Expense, but only while they are incurred during the 90 day period following such termination of insurance.

If a claim is wholly or partially denied, a written notice will be sent to the Insured Person containing the reason for the denial. The notice will include a reference to the provision in the Plan description and a description of any additional information which might be necessary for reconsideration of the claim. The notice will also describe the right to appeal. A written appeal, along with any additional information or comments, may be sent within 6 months after notice of denial. In preparing the appeal, the Insured Person, or his or her representative, may review all documents related to the claim and submit written comments and issues related to the denial. After the written notice is filed and all relevant information is presented, the claim will be reviewed and a final decision sent within 60 days after receipt of the notice of the appeal. Under special circumstances, an extension for further review will be granted, but not for longer than 60 additional days.

If We pay covered expenses for an accident or sickness You incur as a result of any act or omission of a third party, and You later obtain recovery from the third party, You are obligated to reimburse Us for the expenses paid. We may also take subrogation action directly against the third party. Our Reimbursement rights are limited by the amount You recover. Our Reimbursement and Subrogation rights are subject to deduction for the prorata share of Your costs, disbursements and reasonable attorney fees. You must cooperate with and assist Us in exercising Our rights under this provision and do nothing to prejudice Our rights.

This Plan is subject to the Coordination of Benefits provision outlined in the Master Policy. For a complete description, please see the Master Policy.

In the event of an Injury or Sickness the Insured Person should:

1. A claim form is not required to submit a claim. However, an itemized bill, HCFA 1500, or UB92 form should be used to submit expenses. If a referral was required, this form should accompany this submission. The Insured Student/Person's name and identification number need to be included.

2. Providers should submit claims within 90 days from the date of Injury or from the date of the first medical treatment for a Sickness, or as soon as reasonably possible. If a student is submitting the claim, a copy should be retained and claims should be mailed to the Claims Administrator, Klais & Company, Inc., at the address on the back cover.

3. Direct all questions regarding claim procedures, status of a submitted claim or payment of a claim, or benefit availability to the Claims Administrator, Klais & Company, Inc.

4. If you disagree with a claim payment decision, an Insured Person has the right to file an appeal. The process to file an appeal is as follows: (a) you must notify Klais & Company, Inc. within 30 days of the denial. Your claim appeal must be in writing, and clearly state that you are appealing the decision and requesting another review of your claim; and (b) your written appeal should provide specific documentation as to why you believe the decision to be in error, and any new medical information that will be helpful to Klais & Company, Inc. in considering the claim. Klais & Company, Inc. will respond in writing as to their decision. Any provisions of this Policy, which on its effective date, is in conflict with the statues of the state in which the Policy is issued will be administered to conform with the requirements of the state statutes.

Under HIPAA's Privacy Rule, We are required to provide you with notice of our legal duties and privacy practices with respect to personal health information. You should receive a copy of this notice with your enrollment materials. If, at anytime, you wish to request a copy of Combined Insurance Company of America's Privacy Notice, write to 5050 Broadway, Chicago, IL 60640, Attn: HIPAA Privacy Office or call 1-800-225-4500, select HIPAA.

For general information on benefits, on how to enroll, or service issues, please contact:

500 Victory Road

Quincy, MA 02171

1-800-457-5599

Email: Studentcare@Kosterins.com

For information on a specific claim, or to check the

status of a claim, please contact:

1867 West Market Street

Akron, OH 44313-6977

1-800-331-1096

Email: klaisclaims@klais.com

For information on Network Providers, please contact:

(New England)

1-800-922-4286

www.hcvm.com

Or

1-800-247-2898

www.ccnusa.com

For information about the Participating Drug Program, please contact:

1-800-711-0917

www.MedcoHealth.com

This policy is Underwritten by:

Policy Number: CUH200765

A Master Policy is available for review at Middlebury College. In the event of any conflict between this description of services provided and the Policy, the Master Policy will control.