For incidents occurring after September 1, 2019 please use the following procedure
Medical Claim Form
CLAIM PROCEDURES
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 from the member organization, who is not a relative of the claimant, and submit it to Mass Youth Soccer, Attn: Carol Ann Buono. 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 the 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 an 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.
COVERED PERSONS
All registered and affiliated players, coaches, assistant coaches and other adult volunteers of participating member youth soccer organizations are covered by this program if:
1. Their names are listed on a registration report for that organization, and the registration report has been provided to Mass Youth Soccer; and
2. The organization has paid the required affiliation fee to Mass Youth Soccer for all affiliated persons; and
3. The organization has affiliated all participating players and adults, whether the individuals involved are participating in a premier, travel or recreational program.
COVERED ACTIVITIES
Covered persons are eligible for Plan benefits for an injury 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 member organization, provided they are under the direct supervision of a member organization registered adult;
· Sanctioned league games (recreational or travel), provided these activities are sanctioned by Mass Youth Soccer or another US Youth Soccer state soccer association.
· Sanctioned tournaments provided these activities are sanctioned by Mass Youth Soccer, another US Youth Soccer state soccer association or by a Youth Council member in good standing with U.S. Soccer (i.e. US Club Soccer, AYSO, SAY, USASA).;
· Traveling directly to or directly from such scheduled games, practice sessions, or sponsored activity; or
· Participation in an approved indoor activity, summer camp or clinic as described on the website page for these activities.
LIMITED COVERAGE
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: $750 (carry primary insurance) & $1500 (no primary insurance) 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.