Medical Claim Submission Instructions
Medical Claim Form
Massachusetts Youth Soccer Incident Report
Please note that you MUST submit BOTH the claim form and the incident report. You can either scan the forms and e-mail them to Tara Petricca at email@example.com or send them to Mass Youth Soccer, 512 Old Union Turnpike, Lancaster, MA 01523
Claim forms are available through Mass Youth Soccer and are also available on this web site. In the event of injury requiring medical treatment, the Covered Person should fully complete a claim form, have it verified by a witness, who is not a relative of the claimant, and submit it to Mass Youth Soccer, 512 Old Union Turnpike, Lancaster, MA 01523. Notice of claim must be filed within 30 days from the date of injury, unless it can be demonstrated that it was not reasonably possible to do so. Do not wait until all of the medical bills have been received - to initiate the claim, submit all of the appropriate documents within 30 days. Since the Mass Youth Soccer Plan is provided on an "excess" basis, all medical and/or dental charges must first be submitted to any other medical insurance carrier or provider available to the participant. Detailed claim instructions can be found on each claim form.
SUMMARY OF COVERAGE
The following summary applies to the Excess Soccer Accident Medical Benefit Plan that is provided by the Massachusetts Youth Soccer Association (Mass Youth Soccer). This plan is self-funded. All Plan benefits are provided by Mass Youth Soccer. We reserve the right to utilize a third party to administer the Plan on its behalf, and to make benefit determinations based upon information submitted by Covered Person.
The Massachusetts Youth Soccer Plan is an excess medical plan. This means that the Plan benefits are provided only after all other insurance benefits are paid. These other insurance benefits may be provided on a group or individual basis, and may be provided by a traditional insurance indemnity policy, or by a HMO, PPO or other similar arrangement. Medical or dental expenses on behalf of the Covered Person must be submitted to these plans, and an Explanation of Benefits must be provided to Mass Youth Soccer, before the benefits of this Plan will be determined.
TERM OF COVERAGE
Each soccer year begins on September 1st and runs through the following August 31st.
All affiliated players, coaches, assistant coaches and other adult volunteers of participating youth soccer organizations are covered by this program if:
- Their names are listed on a registration report for that organization, and the registration report has been provided to Mass Youth Soccer; and
- The organization has paid the required affiliation fee to Mass Youth Soccer for all affiliated persons; and
- The organization has affiliated all participating players and adults, whether the individuals involved are participating in a premier, travel or recreational program.
Covered persons are eligible for Plan benefits for an injuries that results, directly and independently of all other causes, from an accident that occurs while participating in any of the following covered activities:
- Scheduled games, team practice sessions or other soccer activities sponsored by the affiliated organization, provided they are under the direct supervision of a team official;
- Sanctioned tournaments or games, provided these activities are sanctioned by Mass Youth Soccer or another US Youth Soccer state soccer association;
- Traveling directly to or directly from such scheduled games, practices sessions, or sponsored activity; or
- Participation in an approved indoor activity as described below.
When a member has a primary insurance carrier and elects to seek treatment from a facility that is either not covered or only partially covered by that insurance carrier, Massachusetts Youth Soccer will not cover any additional cost over and above what would have been paid had that member stayed within his or her primary insurance plan. It will be the member's responsibility to provide the documentation proving the coverage amount of his/her insurance carrier.
EXCESS SOCCER ACCIDENT MEDICAL EXPENSE BENEFITS
For reasonable and necessary medical expenses, as determined by Massachusetts Youth Soccer or an approved administrator, the Plan will pay up to $100,000 for injuries sustained in a Covered Activity. Dental injuries are treated like any other injury.
Benefits are paid only after all other insurance benefits have been paid, and then only to the extent any applicable Plan deductible has been satisfied. The current Plan deductibles are: $250 for both medical and dental expenses. If the Covered Person incurs both medical and dental expenses in the same accident, both deductibles apply.
To be eligible for payment, the first expense relating to the accident must be incurred within eight (8) weeks of the date of the accident. No benefit will be paid for any expense that is incurred more than 104 weeks after the date of the accident. An expense is considered to be incurred on the date the medical or dental care is given to the Covered Person.
WHAT IS NOT COVERED
The Plan does not provide coverage for:
- Treatment by persons employed or retained by the affiliated organization, or by family members of the Covered Person;
- Injuries resulting from other than Covered Activities;
- Loss resulting from sickness or disease, except bacterial infection which occurs through an accidental wound;
- The repair, replacement, examinations or prescription, or fitting of eyeglasses or contact lenses;
- Repair or replacement of existing dentures, partial dentures, braces, or other artificial dental restoration;
- Treatment that is incurred by a person who is not a Covered Person; or
- Medical or dental care and treatment that is paid or payable under any other program of insurance. These other programs include group, blanket or franchise health insurance coverage, group hospital or medical service plans, and prepayment coverage; any coverage that is provided by or under a labor-management trustee plan, union welfare plan, employer organization plan, and coverage under any governmental programs, coverage required or provided by any statute, and automobile reparations insurance (no-fault) coverage.
TRAVEL OUTSIDE OF MASSACHUSETTS
All teams traveling outside of Massachusetts in order to participate in a tournament or approved games must be affiliated and must comply with all travel requirements required by USSF, US Youth Soccer and Mass Youth Soccer for the coverage to be in force. This provision applies to both national and international travel.
This Plan will provide the same medical and dental benefits for indoor soccer as for outdoor soccer, but only for the following three situations:
- The team or organization must be participating in an indoor soccer tournament that is sanctioned by Mass Youth Soccer or by another US Youth Soccer state soccer association. Coverage is in force for such activity provided all participants have been affiliated with Mass Youth Soccer.
- The team or organization is conducting indoor practice or training sessions that are not part of an indoor soccer league. Coverage is in force for such activity provided all participants have been affiliated with Mass Youth Soccer.
- For league play where the facility has signed an indemnification agreement with Mass Youth Soccer.
Claim forms are available through Mass Youth Soccer and are also available on this web site. In the event of injury requiring medical treatment, the Covered Person should fully complete a claim form, have it verified by a witness WHO IS NOT A RELATIVE OF THE CLAIMANT, and submit it to Mass Youth Soccer, 512 Old Union Turnpike, Lancaster, MA 01523. Notice of claim must be filed within 30 days from the date of injury, unless it can be demonstrated that it was not reasonably possible to do so. Since the Mass Youth Soccer Plan is provided on an "excess" basis, all medical and/or dental charges must first be submitted to any other medical insurance carrier or provider available to the participant. Detailed claim instructions can be found on each claim form.
THIS OUTLINE IS ONLY FOR GENERAL INFORMATION AND NONE OF THE ABOVE SHALL AMEND OR ALTER THE TERMS OF THE PLAN DOCUMENT. THE WORDING OF THE PLAN DOCUMENT CONTROLS.