SCHOOL OF VISUAL ARTS
STUDENT HEALTH INSURANCE PLAN

FALL 2019 POLICY PERIOD
WAIVER APPEAL FORM

FALL 2019 Waiver Appeal Process: If you missed the fall waiver deadline of October 1, 2019, you may submit a missed waiver deadline appeal for consideration.The deadline to submit a missed waiver deadline appeal is December 6, 2019. You are only eligible for ONE waiver appeal while a student at SVA. If you have used the SVA Student Health Insurance Plan since August 25, 2019, your plan will not be terminated. If your waiver appeal is approved, you will be charged a Late Health Cancellation Fee of $200.

Please note: The waiver appeal is for fall 2019 semester only. After submitting a waiver appeal form, you must ALSO submit a Spring 2020 waiver form at www.sva.edu/uhp.

For more information on submitting a waiver appeal, please contact University Health Plans at 1-800-437-6448 or info@univhealthplans.com.

Important Considerations

This document must be read before you may to continue to the waiver form.

• FALL 2019 Waiver Appeal Process: If you missed the spring waiver deadline of October 1, 2019, you may submit a missed waiver deadline appeal for consideration.The deadline to submit a missed waiver deadline appeal is December 6, 2019. You are only eligible for ONE waiver appeal while a student at SVA. If you have used the SVA Student Health Insurance Plan since August 25, 2019, your plan will not be terminated. If your waiver appeal is approved, you will be charged a Late Health Cancellation Fee of $200.
   
• Please note: The fall 2019 waiver appeal is for fall 2019 semester only. After submitting a waiver appeal form, you must ALSO submit a Spring 2019 waiver form at www.sva.edu/uhp. For more information on submitting a waiver appeal, please contact University Health Plans at 1-800-437-6448 or info@univhealthplans.com.
    
• You will receive an online receipt and email confirmation upon submission of this waiver appeal form. You should retain as evidence that you have submitted the waiver appeal form.
   
• By waiving participation in the SVA-sponsored Student Health Insurance Plan, you are certifying that you have a current health insurance plan with medical coverage that meets or exceeds SVA’s requirements as indicated below and is effective from at least August 25, 2019 through August 24, 2020.
   
• If your current health insurance plan does not meet all of the requirements listed below, you may not waive out of the SVA insurance plan.
   
• If your waiver appeal is not accepted, the Health Insurance Fee will remain on your student account. If you feel your waiver was declined in error, please contact University Health Plans at 1-800-437-6448 or info@univhealthplans.com.

Waiver Requirements

1. The policy must be a US health insurance plan that is filed and approved in the United States
    

2. I confirm that I have a current health insurance plan that includes coverage for:

   • Office visits
   • Prescription drugs
   • Immunizations
   • Routine physical exams
   • Hospitalization, and emergency services.
   • Injuries (resulting from accidents)
   • Inpatient and Outpatient Mental/Behavioral Health Care
      
3. My current health insurance plan is not a short-term limited duration travel plan only.
    
4. My current health insurance plan offers an unlimited maximum benefit for coverage of necessary medical expenses each policy year.
    
5. My current health insurance plan includes a nationwide network of Preferred Providers, guaranteeing acceptance of my insurance plan, especially within the New York City area.
    
6. My current health insurance plan provides coverage anywhere in the world, including medical evacuation, repatriation, and travel assistance services while I am away from campus for academics, research, work, or vacation.
    
7. My current health insurance plan does not limit my coverage to emergency conditions only while in the area of the School of Visual Arts campus, but provides all of the coverage described in #2 above while in the area of the School of Visual Arts campus.

By submitting the online waiver appeal form, I acknowledge that if it is approved, I am legally responsible for any and all medical expenses I incur during the 2019-2020 policy period and that neither SVA nor its Student Health Insurance Plan will be held responsible for any of my medical expenses once I waive coverage. I certify that I have comparable health insurance coverage which meets or exceeds SVA’s requirements as outlined above and which will be in force until August 24, 2020.

THE FALL 2019 WAIVER APPEAL DEADLINE IS DECEMBER 6, 2019.

TO CONTINUE THE WAIVER PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW: