MEMBER ELIGIBILITY

Persons who are non-US citizens, from fourteen (14) days of age and have not yet reached their seventieth* (70) birthday who are traveling to the United States for business, pleasure, to study or to visit who have arrived in the United States within the twenty-four (24) months prior to the proposed Effective Date, who have paid premium as outlined in the enrollment application, and who have completed the enrollment form in complete detail are eligible for Inbound Choice. The Company maintains its right to investigate to verify that the eligibility requirements have been met. If and whenever the Company discovers that the Certificate eligibility requirements have not been met, its only obligation is refund of premium.

The eligibility date for Dependent Child(ren) of a Named Insured (as defined) shall be determined in accordance with the following: (1) If a Named Insured has Dependent Child(ren) on the date he or she is eligible for insurance; or (2) If a Named Insured acquires Dependent Child(ren) after the Effective date, such Dependent Child(ren) becomes eligible on the date the Insured acquires a Dependent Child who is within the limits of a dependent, unmarried child set forth in the “Definition” section of the Certificate. Dependent Child(ren) eligibility expires concurrently with that of the Named Insured.

EFFECTIVE DATE

Effective Date under the program shall become effective at 12:01 AM North American Eastern Time on the latest of the following dates:

1. The day after the Company receives your application and correct premium if application and payment is made online or by fax; or

2. The day after the postmark date of your application and correct premium if application and payment is made by mail; or

3. The moment you depart your Home Country; or

4. The date you request on your application.

Dependent Child(ren) coverage will not be effective prior to that of the Named Insured

EXPIRATION DATE

The coverage provided with respect to the Named Insured shall terminate at 12:01 AM North American Eastern Time on the earliest of the following dates:

1. The date shown on the insurance confirmation card, for which the premium is paid; or

2. The thirty-first (31 st ) day of any Insured Person’s return trip to his or her Home Country whether days of the trip are consecutive or not; or

3. After three hundred and sixty four (364) days of coverage, unless the company agrees to extend coverage upon such expiration; or

4. The date the Named Insured becomes a United States citizen; or

5. The date of entry into active duty military service; or

6. The date the master policy terminates (unless the Company agrees, in writing, to permit coverage to continue to the end of the period for which premiums have been paid in lieu of a return of unearned premiums);

7. In addition, for Dependent Child(ren), coverage expires the date the Named Insured(s) coverage expires or the date they cease to be considered a Dependent Child.

INSURANCE COMPANY

This Insurance, under Certificate LON16-160810-02TM, is underwritten by Certain Underwriters at Lloyds, London, rated A “Excellent” by AM Best.

Entire Contract; Changes: The Certificate, including the Application, Schedule of Benefits, endorsements and the attached papers, if any, constitutes the entire contract of Insurance. No change in the Certificate shall be valid until approved by an executive officer of the Company and unless such approval is endorsed hereon. No agent has authority to change this Certificate or to waive any of its provisions;

Physical Examination and Autopsy: The Company at its own expenses shall have the right and opportunity to examine the person of any individual whose Injury or Illness is the basis of claim when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death, where it is not forbidden by law.

Grace Period: There is no Grace Period associated with this program.

Not in Lieu of Worker's Compensation: This Insurance is not in lieu of and does not affect any requirements for coverage by Worker's Compensation Insurance.

Certificate of Insurance: The Company shall issue to each Insured Person an individual Program Summary (Certificate of Insurance), which shall state the essential features of Insurance to which such person is entitled and to whom benefits are payable, if required to do so by the laws of the locality in which the Insured Person resides when his Insurance becomes effective.

Data Furnished by Insured Person(s): Insured Person shall furnish all information requested on the Application and any additional information requested by the Company.The refusal of the Insured Person, the Insured Person’s Physician, Hospital or Service Provider to make all medical reports and recordsavailable to the Company could cause an otherwise valid claim or Application to be denied or the file to be closed due to lack of or limited reply from the Insured Person’s medical providers. Failure on the part of the Insured Person to maintain adequate documentation regarding travel history could cause an otherwise valid claim (where travel history is material to the benefit and claim) to be denied or the file to be closed.The Company has the option whether or not to consider medical information provided by friends / relatives of the Insured Person as valid for underwriting or claim administration. Assignment: The Insurance provided hereunder is not assignable, but benefits may be assigned in accordance with #5, Payment of Claims.

Excess Benefits: All coverages shall be in excess of all other valid and collectible insurance and shall apply only when such benefits are exhausted.

Other valid and collectible insurance for which benefits may be payable are insurance programs provided by:

1. Individual, group or blanket insurance or coverage;

2. Other prepayment coverage provided on a group or individual basis;

3. Any coverage under labor management trusteed plans, union welfare plans, employer organizational plans, employee benefitorganization plans, or other arrangement of benefits for individuals of a group;

4. Any coverage required or provided by any statute, socialized insurance program; or

5. Any no-fault automobile insurance;

6. Any third party liability insurance

Monetary Limits: The monetary limits stated in this Certificate and the premium shall be in United States dollars. For services outside of the territorial limits of the United States, the exchange rate used to determine the amount of United States dollars to be paid is the exchange rate effective for the date the claims expense was incurred.

Subrogation: The Certificate has the right to full subrogation and reimbursement of any and all amounts paid by the Certificate to or on behalf of, an Insured Person, if the Insured person receives any sum of money from any person, plan or legal entity which is legally obligated to make payments arising out of any act or omission of any person whether a third party or another covered person under the Certificate, which directly or indirectly caused a physical or mental condition, in connection with which payment of any benefits under the Certificate to, or on behalf of, such Insured Person was made. The Certificate shall have a lien against such sum of money received from third parties or other persons described above or their insurers, or the insurer of the Insured Person, and shall be reimbursed therefrom. The Insured Person further agrees to notify other persons described above in writing, of the Certificate's subrogation and lien rights before the receipt of any payment from said parties or other persons.

The Insured Person shall be responsible for all expenses of recovery from such parties or other persons, including but not limited to, all attorneys' fees incurred in collection of such payments or payments by other persons, which fees and expenses shall not reduce the amount of reimbursement to the Certificate required of the Insured Person. The Insured Person agrees to reimburse the Certificate for any benefit paid hereunder, out of any monies recovered from such party or other persons as a result of judgment, settlement or otherwise, even though such monies are not characterized as amounts paid for medical expenses or claims. The Insured Person agrees to furnish such information and assistance, and to execute and deliver all necessary instruments, as the Company or its designee may request to facilitate the enforcement of these subrogation rights, including but not limited to the execution of a subrogation agreement prior to payments of benefits under the Certificate to, or on behalf of the Insured Person.

The Insured Person shall not release or discharge any party from his or her obligation to the Insured Person or the Certificate or take any other action which could impair the Certificate's subrogation rights. The Certificate's exercise of its rights to take whatever action it sees fit against any third party or other persons shall not affect the Insured Person's right to pursue other forms of recovery.

If the Insured Person or any one acting on his or her behalf has not taken action to push his or her rights against such parties or other persons to obtain a judgment, settlement or other recovery, the Company or its designee, upon giving thirty (30) days written notice to the Insured Person shall have the right to take such action in the name of the Insured Person to recover that amount of benefits paid under theCertificate; provided, however, that any action taken without the consent of the Insured Person shall be without prejudice to such Insured Person.

The Certificate's right to reimbursement as set forth herein shall be payable first from sums received from the parties or other persons and such reimbursement shall continue until the Insured Person's obligations hereunder to the Certificate are fully discharges, even though the Insured Person does not receive full compensation or recovery for his/her injuries, damages loss or debt. This right to subrogation protanto shall exist in all cases.

If an Insured Person fails to comply with these requirements, the Insured Person shall not be eligible to receive any benefits, services or payments under the Certificate until there is compliance regardless of whether such benefits are related to the act or omission of such party or other persons.

Fraud and Misrepresentation: Any misstatement, concealment or fraud in the Applicant’s (or Applicant’s authorized representative) statements, either on the Application or on subsequent contact (including any claim submissions), whether in writing or otherwise, to the Company or its representatives, shall render this insurance null and void and all claims hereunder shall be forfeited. In addition, if any fraudulent means or devices are used by any Insured Person (or Applicant) or anyone acting on their behalf, this insurance shall be null and void and all claims hereunder shall be forfeited.

Patient Protection and Affordable Care Act: THIS IS NOT QUALIFYING HEALTH COVERAGE ("MINIMUM ESSENTIAL COVERAGE") THAT SATISFIES THE HEALTH CARE COVERAGE REQUIREMENT OF THE AFFORDABLE CARE ACT. IF YOU DON’T HAVE MINIMUM ESSENTIAL COVERAGE, YOU MAY OWE AN ADDITIONAL PAYMENT WITH YOUR TAXES.

SCHEDULE OF BENEFITS

INJURY AND SICKNESS MEDICAL BENEFITS (PART A)

Maximum Benefit Limit Per Sickness or Injury:

Ages 14 days through 69: Option $50,000 (Plan A), $75,000(Plan B),$100,000 (Plan C),or$130,000(PlanD)

Deductible Per Person Per Sickness or Injury:

Ages 14 days through 69: Option $0, $50, or $100

No Coinsurance applies.

Age 14 Days through 69

Plan A 

Plan B 

Plan C

Plan D

Medical Maximum

$50,000 Max per

Injury/Sickness

$75,000 Max per

Injury/Sickness

$100,000 Max per

Injury/Sickness

$130,000 Max per

Injury/Sickness

Deductible Per Person Per Sickness or Injury

$0, $50, or $100

$0, $50, or $100

$0, $50, or $100

$0, $50, or $100

INPATIENT

 

 

 

 

Hospital Room & Board Including Laboratory Tests,

X-Rays,

Prescription

Medical, Extended Care Facility and other miscellaneous

Up to$1,500/day, 30 day max

Up to $2,000/day, 30 day max

Up to $2,500/day, 30 day max

Upto$3,000/day, 30 day max

Hospital Intensive Care Unit

Additional$500/day, 8 day max

Additional$500/day, 8 day max

Additional$500/day, 8 day max

Additional$800/day, 8day max

Surgical Treatment

Up to $2,100

Up to $4,800

Up to $5,800

Up to $7,200

Anesthetist

Up to $500

Up to $750

Up to $1,000

Up to $1,650

Assistant Surgeon

Up to $500

Up to $750

Up to $1,000

Up to $1,650

Physician’s Non-Surgical Visits

Up to $60/visit, 1/day,10 visits max

Up to $75/visit, 1/day, 10 visits max

Up to $90/visit, 1/day, 10 visits max

Up to $115/visit, 1/day, 10visits max

Private Duty Nurse

Up to $650

Up to $650

Up to $650

Up to $650

A Consulting Physician,

when requested by attending Physician

 

 

Up to $250

 

 

Up to $325

 

 

Up to $500

 

 

Up to $575

Pre-Admission Tests w/in7 days before Hospital admission

Up to $650

Up to $975

Up to $1,300

Up to $1,300

OUTPATIENT

 

 

 

 

Surgical Treatment

Up to $2,100

Up to $4,800

Up to $5,800

Up to $7,200

Anesthetist 

Up to $500

Up to $750 

Up to $1,000

Up to $1,650

Assistant Surgeon 

Up to $500 

Up to $750

Up to $1,000

Up to $1,650

Physician’s Non-Surgical/Urgent Care Visits

Up to $60/visit, 1/day,10visit max

Up to $75/visit, 1/day,10 visits max

Up to $90/visit, 1/day,10 visit max

Up to $115/visit, 1/day, 10 visits max

Diagnostic X-rays & Lab Services

Up to $250 - Additional $325- One CATscan,PET scan or MRI

Up to $375 - Additional $325 - One CAT scan, PET scan or MRI

Up to $500 - Additional $975 – One CAT scan PET scan or MRI

Up to $575 -Additional $975 - One CAT scan, PET scan or MRI

Hospital Emergency

Room (all expenses

incurred therein)

Up to $200

Up to $500

Up to $575

Up to $750

Prescription Drugs

Up to $250 Per Period of Coverage

Up to $250 Per Period of

Coverage

Up to $250 Per Period of

Coverage

Up to $250 Per Period of

Coverage

Outpatient Surgical

Facility - Day surgery

miscellaneous, related to outpatient scheduled surgery performed at a

Hospital or licensed

outpatient surgery center;including the cost of the

operating room,

anesthesia, drugs and medicines and medical supplies.

Up to $600

Up to $900 

Up to $1,200

Up to $1,400

OTHER TREATMENT

AND SERVICES

 

 

 

 

Ambulance Services

Up to $500

Up to $500

Up to $500

Up to $500

Initial Orthopedic

Prosthesis/brace

Up to $663

Up to $994

Up to $1,325

Up to $1,600

Durable Medical

Equipment

Up to $1,100

Up to $1,200

Up to $1,300

Up to $1,700

Chemotherapy and/or radiation therapy

Up to $663

Up to $994 

Up to $1,325

Up to $1,600

Dental Treatment for Injury to Sound, Natural Teeth

Up to $650 

Up to $650

Up to $650

Up to $650

Mental & Nervous

Disorder&Substance

Abuse

Same as any Sickness 

Same as any Sickness 

Same as any Sickness 

Same as any Sickness 

Emergency Evacuation

Physiotherapy

$50,000

Up to $45/visit, 1/day, 12 visits max

$50,000

Up to $45/visit, 1/day, 12 visits max

$50,000

Up to $45/visit, 1/day, 12 visits max

$50,000

Up to $45/visit, 1/day, 12 visits max

Extended Care Facility

Covered under the Hospital Room & Board

benefit

Covered under the

Hospital Room & Board

benefit

Covered under the

Hospital Room & Board

benefit

Covered under the

Hospital Room & Board

benefit

Return of Remains/

Local Cremation/Burial

$25,000

$5,000

$25,000

$5,000

$25,000

$5,000

$25,000

$5,000

Home Country Coverage

$50,000

$50,000

$50,000

$50,000

Common Carrier AD&D

$25,000 Principal Sum

$25,000 Principal Sum

$25,000 Principal Sum

$25,000 Principal Sum

Acute Onset of Pre-

existing Condition(s)

$50,000 per Period of Coverage for Medical Expense Benefits (subject

to the sublimits for each benefit shown above) &

$25,000 per Period of

Coverage for Emergency

Medical Evacuation

$75,000 per Period of

Coverage for Medical Expense Benefits (subject

to the sublimits for each benefit shown above) &

$25,000 per Period of Coverage for Emergency

Medical Evacuation.

$100,000 per Period of

Coverage for Medical Expense Benefits (subject

to the sublimits for each benefit shown above) &

$25,000 per Period of

Coverage for Emergency

Medical Evacuation.

$130,000 per Period of

Coverage for Medical Expense Benefits (subject

to the sublimits for each benefit shown above) &

$25,000 per

 Period of

Coverage for Emergency

Medical Evacuation.

EMERGENCY EVACUATION AND RETURN OF REMAINS (PART B)

BENEFITMAXIMUM AMOUNT
Emergency Evacuation $50,000 maximum benefit per Injury or Sickness
Return of Remains $25,000 maximum benefit

COMMON CARRIER ACCIDENTAL DEATH & DISMEMBERMENT (PART C)

BENEFITPRINCIPAL SUM
Accidental Death & Dismemberment $25,000

BENEFIT PERIOD & HOME COUNTRY COVERAGE

“BENEFIT PERIOD” shall mean the duration of time following an Eligible Accident, Injury or Illness in which to receive Medically Necessary Covered Expenses. If Your plan terminates during Your Benefit Period, You will still be eligible to receive Treatment so long as the treatment is within Your Benefit Period and outside Your Home Country (except as provided under the Home Country Coverage). Treatment due to an Injury must be performed by a Physician and meet the following conditions: a) begin within thirty (30) days after date of Injury; and b) be received within three hundred and sixty-four (364) after date of Injury; or Due to Sickness of an Insured Person provided Covered Medical Expenses are incurred within three hundred and sixty-four (364) after the date of first treatment for such Sickness.

HOME COUNTRY COVERAGE

Incidental Trips to Your Home Country: This benefit covers the Insured Person for incidental trips to his or her Home country (30 days per three hundred and sixty-four (364) days of purchased coverage or pro rata thereof – example: approximately 2½ days per 30 days of purchased coverage). Maximum benefit is reduced to $50,000 for any illness or injury occurring while on an incidental trip to the Home Country.

PRE-EXISTING MEDICAL CONDITIONS

"PRE-EXISTING CONDITION” shall mean any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous Disorder, regardless of the cause including any congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting there from that with reasonable medical certainty existed at the time of application or within the one hundred and eighty (180) days immediately prior to the Insured Person’s Effective Date under the Certificate, whether or not previously manifested, symptomatic, known, diagnosed, treated or disclosed. This specifically includes but is not limited to any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought treatment during the one hundred and eighty (180) days immediately preceding the effective date of coverage under this Certificate.

MEDICAL EXPENSE BENEFITS – INJURY AND SICKNESS

When a covered Injury or Sickness requires treatment by a Physician, the Certificate will provide benefits for the maximum benefit amount payable per service as specified in the Schedule of Benefits for Medically Necessary Covered Medical Expenses which exceed the deductible per person for each Injury or Sickness. The total payable for all Covered Medical Expenses will be no more than the Maximum Benefit Limit per Sickness or Injury.

Benefits are subject to the Excess Provision.

Covered Medical Expenses will be paid under the Schedule of Benefits for loss:

1. Due to Injury to an Insured Person provided that treatment by a Physician: a) begins within thirty (30) days after date of Injury; and b) is received within three hundred and sixty-four (364) days after date of Injury; or

2. Due to Sickness of an Insured Person provided Covered Medical Expenses are incurred within three hundred and sixty-four (364) days after the date of first treatment for such Sickness.

If a benefit is designated in the Schedule of Benefits, Covered Medical Expenses include:

1. Room and Board Expense: 1) daily semi-private room rate when Hospital Confined; and 2) general nursing care provided and charged for by the Hospital.

2. Intensive Care.

3. Hospital Miscellaneous Expenses: 1) while Hospital Confined; or 2) for pre-admission expenses for being Hospital Confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; x-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies.

4. Physiotherapy (inpatient).

5. Surgery: Physician’s fees for inpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this inpatient surgery benefit; or under the outpatient surgery benefit, but not for both.

6. Anesthetist Services: in connection with inpatient surgery.

7. Private Duty Nurse’s Services: 1) private duty nursing care only; 2) while Hospital Confined; 3) ordered by a licensed Physician; and 4) a Medical Necessity. General nursing care provided by the Hospital is not covered under this benefit.

8. Physician’s Visits: when Hospital Confined. Benefits are limited to one Physician’s visit per day. Benefits do not apply when related to surgery. Covered medical expenses will be paid under the inpatient benefit or under the outpatient benefit for Physician’s Visits but not both.

9. Pre-admission Testing: limited to routine tests such as: complete blood count; urinalysis; and chest x-ray. If otherwise payable under the Certificate, major diagnostic procedures such as: cat-scans; NMR’s; and blood chemistries will be paid under the “Hospital Miscellaneous” benefit.

10. Mental and Nervous Disorder (inpatient): the benefits and the maximum amounts are specified in the Schedule of Benefits. Benefits are limited to one Physician’s visit per day.

11. Surgery (outpatient): Physician’s fees for outpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this outpatient surgery benefit; or under the inpatient surgery benefit, but not both.

12. Day Surgery Miscellaneous (Outpatient): in connection with outpatient day surgery; excluding non-scheduled surgery, and surgery performed in a Hospital emergency room, trauma center, Physician’s office, or clinic. Benefits will be paid for services and supplies such as: the cost of the operating room, laboratory tests and x-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies.

13. Anesthetist (Outpatient): in connection with outpatient surgery.

14. Physician’s Visits (Outpatient): Includes injections administered during visit. Benefits do not apply when related to surgery or Physiotherapy. Covered medical expenses will be paid under the outpatient benefit or under the inpatient benefit for Physician’s visits but not both.

15. Medical Emergency Expenses (Outpatient): only in connection with a Medical Emergency as defined. Benefits will be paid for the use of the emergency room and supplies.

16. Radiation Therapy (Outpatient)

17. Chemotherapy (Outpatient)

18. Prescription Drugs (Outpatient)

19. Mental and Nervous Disorder (Outpatient): the benefits and the maximum amounts are specified in the Schedule of Benefits. Benefits are limited to one Physician’s visit per day.

20. Ambulance Service.

21. Braces and Appliances: 1) when prescribed by a Physician; and 2) a written prescription accompanies the claim when submitted. Replacement braces and appliances are not covered. Braces and appliances include Durable Medical Equipment (consisting of a standard basic hospital bed and/or a standard basic wheelchair). No benefits will be paid for rental charges in excess of purchase price.

22. Consultant Physician Fees: when requested and approved by the attending Physician.

23. Dental Treatment: 1) performed by a Physician; and 2) made necessary by Injury to Sound, Natural Teeth. Routine dental care and treatment to the gums are not covered.

24. Alcoholism/Drug Abuse Treatment: the benefits and the maximum amounts are specified in the Schedule of Benefits.

25. Care in an Extended Care Facility following direct transfer from an acute care Hospital, provided such care is recommended by the Physician for convalescence related to the Illness or Injury for which the Member was hospitalized as Inpatient. Extended Care Facility benefits accrue toward the limits for Hospital Room and Board.

EMERGENCY EVACUATION

The Company will pay benefits for covered expenses incurred up to a maximum of $50,000, if an Injury or Sickness commencing during the Period of Coverage results in the necessary Emergency Evacuation of the Insured Person. An Emergency Evacuation must be ordered by a legally licensed Physician who certifies that the severity of the Insured Person's Injury or Sickness warrants the Emergency Evacuation of the Insured Person.

Benefits are subject to the Excess Provision.

Emergency Evacuation means:

1) the Insured Person's medical condition warrants immediate transportation from the place where the Insured Person is injured or sick to the nearest Hospital where appropriate medical treatment can be obtained; or

2) after being treated at a local Hospital, the Insured Person's medical condition warrants transportation to the place where he or she resides to obtain further medical treatment or to recover; or

3) both a) and b) above.

Covered expenses are expenses, up to the maximum, for transportation, medical services and medical supplies necessarily incurred in connection with emergency evacuation of the Insured Person.

All transportation arrangements made for evacuating the Insured Person must be by the most direct and economical route. Seven Corners Assist must make all arrangements and must authorize all expenses in advance for any Emergency Evacuation benefits to be payable

Covered expenses must be: (a) recommended by the attending Physician; (b) required by the standard regulations of the conveyance transporting the Insured Person; and (c) authorized in advance by Seven Corners Assist.

Transportation means any land, water or air conveyance required to transport the Insured Person during an emergency evacuation. Transportation includes, but is not limited to, air ambulance, land ambulance, and private motor vehicles.

RETURN OF REMAINS / LOCAL CREMATION OR BURIAL

The Company will pay the reasonable Covered Expenses incurred up to $25,000 to return the Insured Person's remains to his/her Home Country, if he or she dies. Covered Expenses include, but are not limited to, expenses for embalming, [a minimally necessary container appropriate for transportation, shipping costs, and the necessary government authorizations. All transportation arrangements must be performed by the Administrator.

The Company will pay the reasonable Eligible Expenses incurred up to the maximum stated in the SCHEDULE OF BENEFITS for preparation, local burial or cremation of the Insured Person’s mortal remains at the place of death in accordance with the commonly accepted cultural and religious beliefs practiced by the Insured Person. Coverage is not provided for burial and cremation costs incurred for religious practitioner, flowers, music, food or beverages.

If the Local Cremation or Burial is chosen, the Return of Mortal Remains benefit will not apply.

INTERNATIONAL TRAVEL COVERAGE

An insured person may travel to additional countries, other than the United States, up to a maximum of 30 days. You must purchase a minimum of thirty (30) days of coverage. International travel coverage does not include travel back to the insured person’s Home Country, and it does not extend after your current expiration date. International travel must be utilized during your current Period of Coverage.

COMMON CARRIER ACCIDENTAL DEATH AND DISMEMBERMENT INDEMNITY

Accidental Death & Dismemberment Coverage shall apply only to covered accidents sustained by an Insured Person:

1) While riding as a passenger (but not as a pilot, operator or member of the crew) in or on (including getting in or out of, or on or off of):

A) any land, water or air conveyance operated under a license for the transportation of passengers for hire; or

B) any Military Air Transport Aircraft; or

2) By being struck down by any aircraft.

The Company shall pay an indemnity determined from the Table of Losses below if an Insured Person sustains a loss stated therein resultingfrom Injury, provided that:

(a) such loss occurs within three hundred and sixty five (365) days after the date of accident causing such loss; or

(b) the indemnity payable for any such loss shall be the amount stated opposite such loss in said Table and the Principal Sum stated therein shall be the amount stated in the Schedule of Benefits, as applicable to such person and this Coverage; and

(c) if more than one loss stated in said Table is sustained as the result of one accident, only one of the amounts so stated in said Table, the largest, shall be payable.

For Loss of:Indemnity
Life Principal Sum
Both Hands or Both Feet or Sight of Both Eyes Principal Sum
One Hand and One Foot Principal Sum
Either Hand or Foot and Sight of One Eye Principal Sum
Either Hand or Foot One-Half the Principal Sum
Sight of One Eye One-Half the Principal Sum

The term “loss” as used herein shall mean with regard to hands and feet, actual severance through or above wrist or ankle joints, and with regard to eyes, entire irrecoverable loss of sight.

Exclusion

GENERAL EXCLUSIONS AND LIMITATIONS

No benefits will be paid for loss or expense caused by, contributed to, or resulting from:

  1. Pre-Existing Conditions as defined herein. If you are a non-U.S. citizen under age 70, this exclusion is waived for eligible medical expenses for an Acute Onset of a Pre-existing Condition(s) (as defined herein) as shown in the Schedule of Benefits for your chosen plan (Plan A, B, C, and D). Benefits will be administered as stated in section F, Acute Onset of a Pre-Existing Condition(s), for eligible medical expenses incurred in the United States, minus your Deductible and subject to the scheduled limits for benefits as stated in the Schedule of Benefits. For persons age 70 and over, there is no benefit. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs, or treatments existent or necessary prior to the effective date of this program. Any exclusion specifically listed in General Exclusions and Limitations, numbers 2 through 44, as well as the section entitled Additional Limitations and Exclusions for Elective Surgery and Elective Treatment, will not receive benefits from this waiver;
  2. Any loss that occurs while traveling solely for the purpose of obtaining medical treatment, while on a waiting list for a specific treatment, or while traveling against the advice of a Physician;
  3. Maximum benefit is reduced to $50,000 for any illness or injury occurring while on an incidental trip to the Insured Person’s Home Country;
  4. Routine physical, inoculations or other examinations including but not limited to laboratory, diagnostic, or x-ray examinations where there are no objective indications of impairment of normal health, or well baby care;
  5. Eye examinations; prescriptions or fitting of eyeglasses and contact lenses; eyeglasses, contact lenses; eye surgery when the primary purpose is to correct nearsightedness, farsightedness or astigmatism; or other treatment for visual defects and problems. “Visual Defects” means any physical defect of the eye which does or can impair normal vision;
  6. Hearing examinations or hearing aids; or other treatment for hearing defects and problems. “Hearing Defects” means any physical defect of the ear which does or can impair normal hearing;
  7. Treatment and the provision of false teeth or dentures or dental appliances, normal ear tests and the provision of hearing aids, hearing implants, cosmetic or plastic Surgery (including deviated nasal septum), dental expenses except as specifically provided in the Dental Emergency Treatment benefit;
  8. Services or supplies not necessary for the medical care of the patient’s Injury or Sickness;
  9. Weak, strained or flat feet, corns, calluses, or toenails;
  10. Cosmetic surgery, or treatment for congenital anomalies (except as specifically provided), except reconstructive surgery as the result of a covered Injury or Sickness. Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or Sickness;
  11. Elective surgery and elective treatment;
  12. Treatment, drugs, diagnostic or surgical procedures in connection with infertility, impotency, artificial insemination, sterilization or reversal thereof, unless infertility is a result of a covered Injury or Sickness;
  13. Birth control, including surgical procedures and devices;
  14. Routine new-born baby care, well-baby nursery and related Physician charges;
  15. Injury sustained while participating in professional, sponsored and/or organized Amateur or Interscholastic Athletics; including but not limited to the event, games, practice, conditioning and any other activity related to professional sponsored and/or organized Amateur of Interscholastic Athletics;
  16. Injury sustained while taking part in Mountaineering, hang gliding, parachuting, bungee jumping, racing by any animal or motor vehicle or motorcycle, snowmobiling, motorcycle / motor scooter riding (whether as a passenger or driver), scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, wakeboard riding, jet skiing, windsurfing, snow skiing and snowboarding and any other sport, recreational, athletic, or adventure activity which is undertaken for thrill seeking and exposes the insured to abnormal or extreme risk of injury and/or is in violation of applicable laws, rules, or regulations; Mountaineering shall mean the sport, hobby or profession of walking, hiking, and climbing up mountains either:
  17. utilizing harnesses, ropes, crampons or ice axes; or
  18. ascending 4500 meters or above.
  19. Treatment paid for or furnished under any other individual, government, or group policy; previous Certificate; payable under any Worker’s Compensation or Occupational Disease Law or Act; or charges provided at no cost to the Insured Person;
  20. Occupational Diseases, including but not limited to Disease(s) related to asbestos exposure, and the complications thereof, including asbestosis and mesothelioma related to asbestos exposure;
  21. Treatment for human organ or tissue transplants and their related treatment;
  22. War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the Insured Person or the country in, or over, which the act occurs, Civil war, Riot, Rebellion, Insurrection, Revolution, Overthrow of the legally constituted government, Civil commotion assuming the proportions of, or amounting to, an uprising, Military or usurped power, Explosions of war weapons, Utilization of Nuclear, Chemical or Biological weapons of mass destruction howsoever these may be distributed or combined, Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the Insured Person whether war be declared with that state or not, Terrorist activity. For the purpose of this Exclusion; i) Terrorist activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s). ii) Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals. iii) Utilization of Chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals. iv) Utilization of Biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death amongst people or animals. Also excluded hereon is any Loss or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of the situations described above. In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect;
  23. Suicide or any attempt thereof, or self-destruction or any attempt thereof; intentionally self-inflicted Injury or Illness;
  24. Charges of an institution, health service, or infirmary for whose service payment is not required in the absence of insurance;
  25. Treatment of nervous or mental disorders, or Treatment in connection with alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency or use of any drug or narcotic agent; Injury sustained while under the influence of or Disablement due wholly or partly to the effects of intoxicating liquor, chemicals, or drugs or narcotic agent, unless administered under the advice of a Physician and said narcotic agent was taken in accordance with the proper dosing as directed by the physician; unless prescribed by a Physician, except as stated in the Schedule of Benefits for mental or nervous disorders;
  26. Loss incurred from riding in any aircraft, other than as a passenger in an aircraft licensed for the transportation of passengers;
  27. Treatment, services, supplies or facilities in a Hospital owned or operated by: a) the Veteran’s Administration; or b) a national government or any of its agencies. (This exclusion does not apply to treatment when a charge is made which the Insured is required by law to pay);
  28. Duplicate services actually provided by both a certified nurse-midwife and Physician;
  29. Expenses payable under any prior Certificate which was in force for the person making the claim;
  30. Expenses incurred during a Hospital emergency room visit which are not of an emergency nature;
  31. Expenses incurred for outpatient treatment in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column;
  32. Injury sustained as the result of the Insured operating a motor vehicle while not properly licensed to do so in the jurisdiction the motor vehicle accident occurs;
  33. Voluntary or elective abortion;
  34. Expenses covered by any other valid and collectible medical, health or accident insurance;
  35. Expenses incurred after the date insurance terminates for an Insured Person except as may be specifically provided;
  36. Treatment and or diagnosis of venereal disease , including all sexually transmitted diseases and conditions , and any and all consequences thereof;
  37. Treatment(s) which is incurred by an Insured Person(s) who is HIV Positive (i.e., infected with the human immunodeficiency virus, the cause of acquired immunodeficiency syndrome) at the time of Application for this Insurance, whether or not the Insured Person(s) was asymptomatic or symptomatic or had knowledge of his/her HIV status on the initial Effective Date of Coverage, or any associated diagnostic tests or charges for HIV infection, seropositivity to the AIDS virus, AIDS related Illness(es), ARC Syndrome, AIDS, and all diseases caused by and/or related to HIV;
  38. Treatment(s) for HIV, the AIDS virus, AIDS related Illness(es), ARC Syndrome, AIDS, and all diseases and illnesses caused by and/or related to HIV or arising as complications from these conditions including but not limited to the cost of testing for these conditions and/or charges for drug treatment(s) or surgeries;
  39. Treatment for tuberculosis, malaria, cholera, dengue fever and parasitic-sourced illnesses, including but not limited to treatment required as a result of complications from those same diseases, whether or not previously manifested or symptomatic prior to the effective date of the Certificate;
  40. Charges incurred for treatment or surgeries which are Experimental / Investigational, or for research purposes; expenses which are non-medical in nature, expenses for custodial care, vocational, speech, recreational or music therapy;
  41. Expenses for services or supplies which are not recommended, approved and certified as Medically Necessary and reasonable by a Physician;
  42. Chiropractic care or complementary medicine including but not limited to acupuncture and massage;
  43. Services, supplies, or treatment prescribed, performed or provided by a Relative of the Insured Person or any family member of the Insured Person or anyone who lives with the Insured Person. This includes but is not limited to prescription medication and any diagnostic testing;
  44. Diagnosis or treatment of the Temporomandibular joint;
  45. Treatment required as a result of complications or consequences of a treatment or for a condition not covered under this Certificate;
  46. Expenses for home health care, custodial care and/ or daily living, including but not limited to food, housing, or home maker services;
  47. Expenses for environmental supplies, including but not limited to handrails, ramps, special telephones, air conditioners, or home delivered meals.
  48. Pregnancy expenses or Sickness resulting from pregnancy, childbirth, or miscarriage; or for miscarriage resulting from Injury;

ADDITIONAL LIMITATIONS AND EXCLUSIONS FOR ELECTIVE SURGERY AND ELECTIVE TREATMENT:

There are no benefits provided for the following: Elective surgery and elective treatment including but not limited to surgery and/or treatment for acne; acupuncture; allergy; including allergy testing; alopecia; biofeedback-type services; birth control; breast implants; breast reduction;circumcision; corns, calluses and bunions; cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under the Certificate; family planning; fertility tests; gynecomatia; hirsutism; impotence, organic or otherwise; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; learning disabilities; nasal and sinus surgery; nicotine addiction; nonmalignant warts, moles and lesions; obesity and any condition resulting therefrom (including hernia of any kind); patient controlled anesthesia treatment of a covered Injury; sexual reassignment surgery; skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; sleep disorders, including testing thereof; temporomandibular joint dysfunction, tubal ligation; vasectomy; and weight reduction. Elective surgery and elective treatment includes any service, treatment; or supplies that: 1) are deemed by the company to be researched or experimental; or 2) are not recognized and generally accepted medical practices in the United States.

 

Age 14 Days To Age 69 Plan A- $50,000

Age 14 Days To Age 69 Plan B- $75,000

Age 14 Days To Age 69 Plan C - $100,000

Age 14 Days To Age 69 Plan D - $130,000

Acute Onset of a Pre-existing Condition

$50,000 per Period of

Coverage for Medical

Expense Benefits (subject

to the sublimits for each

benefit shown above) &

$25,000 per Period of

Coverage for Emergency

Medical Evacuation.

$75,000 per policy period for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation.

$100,000 per policy period for Medical Expense Benefits (subjectto the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation

$130,000 per policy period for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per policy period for Emergency Medical Evacuation.

ACUTE ONSET OF PRE-EXISTING CONDITION

If You are a non-U.S. citizen under age 70, traveling in the United States, you are covered for an Acute Onset of a Pre-existing Condition(s) as defined in the Definitions section. To be considered a Covered Expense under this benefit, the expenses for an Acute Onset must be incurred in the United States and must be a result of an Acute Onset which occurs in the United States. Coverage is provided per Period of Coverage, to the limit shown in the Schedule of Benefits for Eligible Medical Expenses for your chosen plan (Plan A, B, C and D).Your deductible applies to this coverage, and it is paid according to the sublimits for benefits listed in the Schedule of Benefits above.

An Acute Onset of a Pre-existing Condition(s) is defined as a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms and is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the effective date of the Certificate. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to the Effective Date of coverage.

EXCLUSION

Pre-Existing Conditions as defined herein. If you are a non-U.S. citizen under age 70, this exclusion is waived for eligible medical expenses for an Acute Onset of a Pre-existing Condition(s) (as defined herein) as shown in the Schedule of Benefits for your chosen plan (Plan A, B, C, and D). Benefits will be administered as stated in section F, Acute Onset of a Pre-Existing Condition(s), for eligible medical expenses incurred in the United States, minus your Deductible and subject to the scheduled limits for benefits as stated in the Schedule of Benefits. For persons age 70 and over, there is no benefit. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs, or treatments existent or necessary prior to the effective date of this program. Any exclusion specifically listed in General Exclusions and Limitations, numbers 2 through 44, as well as the section entitled Additional Limitations and Exclusions for Elective Surgery and Elective Treatment, will not receive benefits from this waiver;

Renewal

Coverage may be renewed, if available, and in the discretion of the Company, for additional periods at the premium rate in force at the time of renewal. The maximum total period of coverage for any one (1) Insured Person cannot exceed seven hundred and twenty-eight days (728) days or two (2) consecutive and continuous Period of Coverages (the maximum length of each Period of Coverage is three hundred and sixty-four (364) days). Individuals who have their 70 th birthday during their Period of Coverage will continue to be covered through their current Period of Coverage but will not be allowed to renew once that Period of Coverage expires. There is a $5 admin fee each time you renew, and renewal notices will be provided to you via e-mail. Additionally, the company may change aspects of the program, including rates, at any renewal date.

CANCELLATION

REFUND PROCEDURE Seven Corners realizes that there is uncertainty in international travel. Refund of total plan cost will only be considered if written request is received by Seven Corners prior to the Effective Date of Coverage. If written request is received after the Effective Date of coverage, the unused portion of the plan cost may be refunded minus a cancellation fee, provided no claim has been submitted to Seven Corners for reimbursement.

If this Certificate provides for cancellation and this Certificate is cancelled after the inception date, earned premium must be paid for the time the insurance has been in force.

The Certificate is renewable for up to a total period of three hundred and sixty-four (364) days. The Company may cancel an entire class of Insured Persons based upon claims experience in a certain region or within a gender / age category.

Proof of Loss

Written Proof of Loss, which will include, but not limited to: original signed and dated claim form, original receipts and bills, copies of medical records; must be furnished to Seven Corners, at its said office, within ninety (90) days after the date of such Disablement. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible. In any case, the proof required must be given no later than one (1) year from the time specified except in the absence of legal capacity. The Company at its option may pend resolution and adjudication of submitted claims and/or deny coverage for Proof of Loss submitted thereafter, or for incomplete Proof of Loss and/or failure to submit Proof of Loss.

Claims Submission

  • All claims must be submitted to Seven Corners within 90 days of the date of service.
  • Claims may be mailed, faxed, or scanned. Contact details provided above.
  • A Proof of Loss form must be completed and provided for each medical condition.
  • A copy of your passport with entry/exit/visa stamps is required.
  • Detailed bills for services received and detailed receipts for payments made.
  • A signed authorization from the Insured is necessary to reimburse any person other than the Insured.

Claims Services

Important Note: Claim forms and receipts for medical expenses must be sent to Seven Corners quickly. Claim submissions must be made within ninety (90) after the Date of Service. Should they be received after ninety (90) days, they may be considered ineligible.

To report claims or verify eligibility, send the original bills and claim forms to Seven Corners, Inc., or call or fax to the numbers below. Be certain to include Your ID# shown on the ID Card with all correspondences:

Seven Corners, Inc.
303 Congressional Blvd; Carmel, IN 46032
800-335-0477 or 317-575-2652 FAX 317-575-2256
email: claims@sevencorners.com www.SevenCorners.com

Claim Forms

The Company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing Proofs of Loss. If such forms are not furnished within fifteen (15) days after the giving of such notice the claimant shall be deemed to have complied with the requirements of the Certificate as to Proof of Loss upon submitting, within the time fixed in the Certificate for filing Proofs of Loss, written proof covering the occurrence, the character and the extent of the Disablement for which claim is made.

Payment of Claims

Subject to any written direction of the Insured Person all or a portion of any indemnities provided by this Certificate on account of Hospital, nursing, medical or Surgical service may, at the Company's option and unless the Insured Person requests otherwise in writing not later than the time for filing proof of such loss, be paid directly to the Hospital or person rendering such services.

Notice of Claim

Written notice of claim must be given to the Company within ninety (90) days after the occurrence or commencement of any Disablement covered by the Certificate, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the claimant to the Administrative Offices of the Company, or to any authorized agent of the Company, with information sufficient to identify the Insured Person shall be deemed notice to the Company.

Legal Actions

Any disputes arising from this Certificate or its alleged breach may, if not resolved by the parties, be referred to arbitration by either party pursuant to the commercial arbitration rules of the American Arbitration Association (“AAA”). Either party may make a Inbound Choice 15 LON16-160810-02TM demand for arbitration and such arbitration shall be conducted in Carmel, Indiana, and judgment on any award rendered in such arbitration may be entered in any state or federal court in Indiana. Notices in connection with such arbitration and process in any judicial proceeding in connection wherewith may be served by personal delivery or registered mail on the Company at 303 Congressional Boulevard, Carmel, Indiana 46032 and on the Insured Person(s) at the most current address appearing in the records of the Company, with the same effect as if personally served in Carmel, Indiana.

Arbitration shall be before a single arbitrator jointly selected by the parties hereto. If the parties are unable to agree on an arbitrator within thirty (30) days after the arbitration demand is filed, the AAA shall select the arbitrator. The arbitration filing fee, if any, and fees of the arbitrator shall initially be shared equally between the parties, provided however, that the prevailing party shall be reimbursed for these costs by the non-prevailing party at the conclusion of the arbitration proceeding. Each side shall bear their own legal fees and costs and any other fees associated with participating in the arbitration process. All fees and expenses of the arbitration shall be borne by the parties equally.

The arbitrators are precluded from awarding punitive, treble or exemplary damages, however so denominated. If more than one insured is involved in the same dispute arising out of the same Certificate and relating to the same Loss or claim, all such Insured(s) will constitute and act as one party for the purposes of the arbitration. Nothing in this clause will be construed to impair the rights of the Insured(s) to assert several, rather than joint, claims or defenses.

No actions at law or in equity shall be brought to recover on the Certificate prior to the expiration of sixty (60) days after written Proof of Loss has been furnished in accordance with the requirements of this Certificate. No such action shall be brought after expiration of three(3) years after the time that written Proof of Loss is required to be furnished.

Service of Suit

It is agreed that in the event of the failure of Underwriters to pay any amount claimed to be due hereunder, Underwriters, at the request of the Assured, will submit to the jurisdiction of a Court of competent jurisdiction within the United States. Nothing in this Clause constitutes or should be understood to constitute a waiver of Underwriters’ rights to commence an action in any Court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another Court as permitted by the laws of the United States or of any State in the United States. It is further agreed that service of process in such suit may be made upon Mendes and Mount; 750 Seventh Avenue; New York, NY 10019-6829 USA (For California residents, contact Eileen Ridley, FLWA Service Corp., c/o Foley & Lardner LLP, 555 California Street, Suite 1700, San Francisco, CA 94104-1520 USA.), and that in any suit instituted against any one of them upon this contract, Underwriters will abide by the final decision of such Court or of any Appellate Court in the event of an appeal.

The above-named are authorized and directed to accept service of process on behalf of Underwriters in any such suit and/or upon request of the Assured to give a written undertaking to the Assured that they will enter a general appearance upon Underwriters’ behalf in the event such a suit shall be instituted.

Further, pursuant to any statute of any state, territory or district of the United States which makes provision therefor, Underwriters hereby designate the Superintendent, Commissioner or Director of Insurance or other officer specified for that purpose in the statute, or his successors in office, as their true and lawful attorney upon whom may be served any lawful process in any action, suit or proceeding instituted by or on behalf of the Assured or any beneficiary hereunder arising out of this contract of insurance, and hereby designate the above-mentioned as the person to whom the said officer is authorized to mail such process or a true copy thereof.

Send completed claim documents to Seven Corners
Download Claim Forms Email Fax Mail Claim Enquiry

Injury and Illness Proof of Loss form

claims@sevencorners.com 1 (317) 575-2659

P.O. Box 303, Congressional Boulevard, Carmel, IN 46032

800-335-0611

or

1 (317) 575-2652