Patriot Exchange Program -Excluding Residence

Detail

If an Insured Person is not eligible, this Certificate is void ab initio and all premium paid will be refunded. In order to be eligible and qualified for coverage under this insurance, a person must:

be an active participant in a study and exchange program (i.e.; student visa, exchange visitor visa, visitor visa) the Spouse of the participant, or a Dependent traveling with the participant and residing outside his/her Home Country for the purpose of pursing international educational activities for a temporary period of time; and
on the Effective Date, be physically and legally residing in the Destination Country with the intent to reside there for at least thirty (30) days
complete and sign an Application as the Insured Person (or be listed thereon by proxy as an applicant and proposed Insured Person), and/or as the Insured Person’s spouse and/or Child; and
pay the required Premium on or before the Effective Date of Coverage; and
receive written acceptance of his/her Application or renewal from the Company; and
be at least thirty one (31) days old but not yet sixty-five (65) years old; and
not be Hospitalized or Disabled on the Initial Effective Date; and
not be HIV+ on the Initial Effective Date.

Benefit

Coverage Limit / Maximum Amount for Eligible Medical Expenses
Certificate Period of Coverage	Maximum Limit: 365 days
Maximum Limit	$5,000,000
Per Illness or Injury limit	Refer to the Declaration of Insurance
The per Illness or Injury limits accumulate towards the Maximum Limit.
Area of Coverage	Worldwide excluding the Insured Person’s Country of Residence
Benefit Plan Features
Benefit Levels	United States	United States	International
	In-Network	Out-of-Network	International
Deductible for Eligible Medical Expenses
Deductible Per Illness or Injury	Refer to the Declaration of Insurance
Coinsurance for Eligible Medical Expenses
Coinsurance In addition to Deductible	Plan pays 90% Insured pays 10%	Plan pays 80% Insured pays 20%	Plan pays 100% Insured pays 0%
Out of Pocket Maximum	$1,000	Up to the Maximum Limit	$0
Student Health Center
Copayment per visit Not subject to the per Illness or Injury Deductible Copayment is not applicable if the Declaration states a $0 Deductible	$5
Coinsurance	Plan pays 100% Insured pays 0%
Pre-certification
Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met. Emergency Medical Evacuation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION provision for complete requirements and coverage. All other Treatments & supplies: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met. Maximum Penalty: $1,000 Deductible is taken after reduction. Coinsurance is applied to remainder of the reduced amount. Refer to the PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre- certification.
Pre-existing Conditions
Charges resulting directly or indirectly from or relating to any Pre-existing Condition that existed within 36 months prior to the Effective Date are excluded until the Insured Person has maintained 12 months of continuous coverage under this insurance. Period of Coverage Limit (after 12 months): $500 Maximum Limit: $1,500

Inpatient or Outpatient Services Subject to Deductible unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Benefit	In-Network	Out-of-Network	International
Eligible Medical Expenses	90%	80%	100%
Physician / Specialist Visit Maximum Visits per day: 1 (unless visit is for a different medical/surgical specialty)	90%	80%	100%
Urgent Care Not subject to Deductible Copayment: $50 Copayment is not applicable if the Declaration states a $0 Deductible	90%	80%	100%
Walk-in Clinic Not subject to Deductible Copayment: $20 Copayment is not applicable if the Declaration states a $0 Deductible	90%	80%	100%
Hospital Emergency Room Injury: Not subject to Emergency Room Deductible Illness: Subject to a $500 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission.	90%	80%	100%
Hospitalization / Room & Board Average semi-private room rate Includes nursing, miscellaneous and Ancillary Services	90%	80%	100%
Intensive Care	90%	80%	100%
Bedside Visit Not subject to Deductible Maximum Limit: $1,500 Hospitalized in an Intensive Care Unit Refer to the BEDSIDE VISIT provision for further details	90%	80%	100%
Outpatient Surgical / Hospital Facility	90%	80%	100%
Laboratory	90%	80%	100%
Radiology / X-ray	90%	80%	100%
Pre-admission Testing	90%	80%	100%
Surgery	90%	80%	100%
Reconstructive Surgery Surgery is incidental to and follows Surgery that was covered under the plan	90%	80%	100%
Assistant Surgeon 20% of the primary surgeon’s eligible fee	90%	80%	100%
Anesthesia	90%	80%	100%

Inpatient or Outpatient Services

Subject to Deductible unless otherwise noted

Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit

Benefit

In-Network

Out-of-Network

International

Durable Medical Equipment

90%

80%

100%

Chiropractic Care

Medical order or Treatment plan required

90%

80%

100%

Physical Therapy

Maximum Visits per day: 1
Medical order or Treatment plan required

90%

80%

100%

Extended Care Facility

Upon direct transfer from an acute care Hospital

90%

80%

100%

Home Nursing Care

Provided by a Home Health Care Agency
Upon direct transfer from an acute care Hospital

90%

80%

100%

Prescription Drugs and Medication

Subject to Deductible unless otherwise noted

Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage

The following Prescription Drugs and Medication Period of Coverage limit accumulates toward the Maximum Limit

Prescription Drugs and Medication

Period of Coverage limit: $250,000 per person
Obtained through Retail Pharmacy, Inpatient and Outpatient Surgery, Emergency Room and Outpatient Office Visits
Dispensing maximum for Retail Pharmacy: 90 days per prescription

Not Applicable

90%

100%

Mental or Nervous / Substance Abuse

Subject to Deductible unless otherwise noted

Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit

Inpatient Mental or Nervous / Substance Abuse

Maximum Limit: $10,000
Not covered if incurred at the Student Health Center

90%

80%

100%

Outpatient Mental or Nervous / Substance Abuse

Maximum Limit per day: $50
Maximum Limit: $500
Not covered if incurred at the Student Health Center

90%

80%

100%

Emergency Services

NOT Subject to Deductible unless otherwise noted

Eligible Medical Expenses are limited to Usual, Reasonable and Customary

Limits per Period of Coverage unless stated as Maximum Limit

Benefit

In-Network

Out-of-Network

International

Emergency Local Ambulance

Subject to Deductible
Injury
Illness resulting in a Hospitalization admission

100%

Emergency Medical Evacuation

Maximum Limit: $50,000
Must be approved in advance and coordinated by the Company

100%

Emergency Reunion

Maximum Limit: $15,000
Maximum Days: 15
Meal Maximum per day: $25
Reasonable and necessary travel costs and accommodations
Must be approved in advance by the Company

100%

Interfacility Ambulance Transfer

Up to the per Injury or Illness limit
Services rendered in the United States
Transfer must be a result of an Inpatient Hospital admission

100%

Not Applicable

Political Evacuation and Repatriation

Maximum Limit: $10,000
Must be approved in advance by the Company

100%

Repatriation for Medical Treatment

Maximum Benefit: $100,000
Approved in advance and coordinated by the Company
Refer to the REPATRIATION FOR MEDICAL TREATMENT provision for further details

100%

Return of Mortal Remains

Maximum Limit: $25,000
Local Burial / Cremation at place of death

o Maximum Limit: $5,000

Return of Insured Person’s Mortal Remains to Country of Residence
Must be approved in advance by the Company

100%

Other Services

NOT subject to Deductible unless otherwise noted

Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit

Benefit

In-Network

Out-of-Network

International

Accidental Death & Dismemberment

Principal Sum Maximum: $25,000
Death must occur within 90 days of the Accident

Accidental Death: 100% of Principal Sum

Accidental Dismemberment:

Loss Percent of Principal Sum

Sight of 1 eye 50%

1 hand or 1 foot 50%

1 hand and loss of sight of 1 eye 100% 1 foot and loss of sight of 1 eye 100% 1 hand and 1 foot 100%

Both hands or both feet 100%

Sight of both eyes 100%

Dental Treatment

Period of Coverage Limit: $350

(Treatment due to Unexpected pain to sound, natural teeth)

Period of Coverage Limit per Injury: $500 (Non-emergency Treatment at a Dental Provider due to an Accident)

Not Applicable

90%

100%

Traumatic Dental Injury

Subject to Deductible and Coinsurance
Up to the Maximum Limit
Treatment at a Hospital Facility due to an Accident
Additional Treatment for the same Injury rendered by a Dental Provider will be paid at 100%

90%

80%

100%

Incidental Trip

Maximum days: 14
Country of Residence is outside the United States
Refer to the INCIDENTAL TRIP provision for further details

90%

80%

100%

Terrorism

Maximum Limit: $50,000

100%

ELIGIBLE MEDICAL EXPENSES: Subject to the Terms of this insurance, and the insurance plan shown in the Declaration, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY for the following costs, Charges and expenses incurred by the Insured Person during the Period of Coverage with respect to an Illness or Injury suffered or sustained by the Insured Person during the Period of Coverage and while this Certificate is in effect, so long as the Illness or Injury is covered under this Certificate, Charges are Usual, Reasonable and Customary and are incurred for Treatment or supplies that are Medically Necessary (“Eligible Medical Expenses”):

(1) Charges incurred at a Hospital for:

(a) daily room and board, nursing services, and Ancillary Services not to exceed the average semi-private room rate. A private room will be considered when no semi-private room is available or if medical necessity warrants this type of room. The private room rate is not to exceed the average private room rate.

(b) daily room and board, nursing services, and Ancillary Services in an Intensive Care Unit

(d) services and supplies that are routinely provided by the Hospital to persons for use while an Inpatient

(e) Emergency Treatment of an Injury, even if Hospital confinement is not required

(f) Emergency Treatment of an Illness; however, an additional Deductible (as shown in the BENEFIT SUMMARY) will be required unless the Insured Person is directly admitted to the Hospital as Inpatient for further Treatment of that Illness

(2) Charges incurred for Surgery at an Outpatient Surgical Facility, including services and supplies

(3) Charges by a Physician for professional services rendered, including Surgery; provided, however, that Charges by or for an assistant surgeon will be limited and covered at the rate of up to twenty percent (20%) of the Usual, Reasonable and Customary charge of the primary surgeon; and provided, further, that the standby availability of a Physician or surgeon will not be deemed to be a professional service and is not eligible for coverage

(4) Charges incurred for:

(a) dressings, sutures, casts or other supplies that are Medically Necessary

(b) diagnostic testing using Radiology, ultrasonography or laboratory services. Laboratory services billed for professional component fees are covered if the pathologist has direct involvement in providing a written report or verbal consultation for specimen-specific pathology services

(c) Implant devices that are Medically Necessary; however, any Implants provided outside the PPO network are limited to a payment of no more than one hundred fifty percent (150%) of the established invoice price and/or list price for that item

(d) basic functional artificial limbs, eye or larynx or breast prostheses, but not the replacement or repair thereof

(e) reconstructive Surgery when the Surgery is incidental to and follows Surgery that was covered hereunder

(f) radiation therapy or Treatment, and chemotherapy

(g) hemodialysis for the Treatment of acute renal failure only and the Charges by a Hospital for processing and administration of blood or blood components

(h) oxygen and other gases and their administration

(i) anesthetics and their administration by a Physician

(j) drugs that require a prescription by a Physician for Treatment of Illness or Injury, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of ninety (90) days of any one

(1) prescription

(k) care in a licensed Extended Care Facility upon direct transfer from an acute care Hospital

(l) Home Nursing Care in bed by a qualified licensed professional, provided by a Home Health Care Agency upon direct transfer from an acute care Hospital

(m) Emergency Local Ambulance Transport necessarily incurred in connection with:

(i) an Injury

(ii) an Illness resulting in Hospital confinement as an Inpatient.

(n) Interfacility Ambulance Transfer must be a result of an Inpatient Hospital Admission, Medically Necessary and from one licensed health care Facility to another licensed health care Facility via air or land ambulance

(o) Treatment of Mental or Nervous Disorders and Substance Abuse provided such Treatment is not incurred at a Student Health Center

(p) chiropractic services prescribed by a Physician and performed by a professional chiropractor, and necessarily incurred to continue recovery from a covered Injury or covered Illness; services include manipulations, x-rays and laboratory tests ordered by the chiropractor

(q) physical therapy prescribed by a Physician and performed by a professional physical therapist, and necessarily incurred to continue recovery from a covered Injury or covered Illness

(r) Durable Medical Equipment, as defined herein, deemed to be Medically Necessary

(5) Charges incurred for a Teleconsultation or Virtual Physician Visit

(6) Charges for Treatment resulting from COVID-19/SARS-CoV-2

(7) Charges incurred for Treatment at an Urgent Care Clinic

(8) Charges incurred for Treatment at a Walk-in Clinic

(9) Charges for Treatment of an Injury to the foot due to an Accident covered hereunder

(10) Charges for Treatment of an Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of Treatment

(11) Charges for Dental Treatment as follows up to the amount shown in the BENEFIT SUMMARY:

(a) Charges for Treatment following Traumatic Dental Injury from a covered Accident that resulted in physical Injury to the Insured Person

(b) Charges for necessary Dental Treatment of Unexpected pain to sound natural teeth

(12) Charges for value-added tax (VAT) or like tax incurred on Eligible Medical Expenses.

A. ACCIDENTAL DEATH AND DISMEMBERMENT:

(1) ACCIDENTAL DEATH: Subject to the Terms of this insurance, and in the event the Insured Person has an Accident during the Period of Coverage that results in death during the Period of Coverage, the Company will pay an Accidental Death benefit in the amount of the Principal Sum shown in the BENEFIT SUMMARY.

The Insured Person’s death must occur within ninety (90) days of the Accident and result, directly and independently of all other causes, from an accidental bodily Injury that is unintended, unexpected, and unforeseen. The bodily Injury must be evidenced by a visible contusion or wound, except in the case of accidental drowning. The bodily Injury must be the sole cause of death. The Company will pay the benefit owed upon proper application therefor, in the following order:

(a) to the beneficiary designated in writing by the Insured Person

(b) to the Insured Person’s closest surviving Relative

(d) to a claimant entitled to payment under applicable small estate affidavit laws.

(2) DISMEMBERMENT: Subject to the Terms of this insurance and if the Insured Person has an Accident during the Period of Coverage which results in a loss identified in the BENEFIT SUMMARY within ninety (90) days from the date of the Accident and during the Period of Coverage, the Company will reimburse the Insured Person the applicable loss/dismemberment shown in the BENEFIT SUMMARY.

The maximum benefit payable for all dismemberments or losses resulting from any one (1) Accident or Injury shall not exceed the Principal Sum shown in the BENEFIT SUMMARY for Accidental Death.

The loss of a hand or foot means the complete severance at or above the wrist or ankle joint. The loss of sight means the entire and irrecoverable loss of sight. The Insured Person’s dismemberment must result, directly and independently of all other causes, from an accidental bodily Injury which is unintended, unexpected, and unforeseen. The bodily Injury must be evidenced by a visible contusion or wound. The bodily Injury must be the sole cause of dismemberment.

BEDSIDE VISIT: Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and if the Insured Person is Hospitalized as an Inpatient in the Intensive Care unit of a Hospital for a covered life-threatening Injury or Illness during the Period of Coverage, the Company will reimburse the cost of a round-trip economy commercial airline ticket for one (1) Relative from the airport nearest to the location of the Relative at the time of the Insured Person’s Inpatient Intensive Care Hospitalization to the airport serving the area where the Insured Person is Hospitalized.

J. EMERGENCY MEDICAL EVACUATION:

(1) Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and the CONDITIONS AND RESTRICTIONS subparagraph below, the Company will reimburse the Insured Person for the following transportation costs, when the Company or Plan Administrator arranges such transportation and expenses incurred by the Insured Person arising out of or in connection with an Emergency Medical Evacuation occurring while this Certificate is in effect and during the Period of Coverage:

(a) Emergency air transportation to a suitable airport nearest to the Hospital where the Insured Person will receive Treatment

(b) Emergency ground transportation necessarily preceding Emergency air transportation and from the destination airport to the Hospital where the Insured Person will receive Treatment

(c) Return ground and air transportation, upon medical release by the attending Physician, to the country where the evacuation initially occurred or to the Insured Person’s Country of Residence, at the Insured Person’s option.

(2) CONDITIONS AND RESTRICTIONS: To be eligible for coverage for Emergency Medical Evacuation benefits, the Insured Person must be in compliance with all Terms of this insurance. The Company will provide Emergency Medical Evacuation benefits only when the condition, Illness, Injury or occurrence giving rise to the Emergency Medical Evacuation is covered under the Terms of this insurance. The Company will provide Emergency Medical Evacuation benefits only when all of the following conditions and restrictions are met:

(a) Medically Necessary Treatment cannot be provided locally

(b) transportation by any other means or methods would result in loss of the Insured Person’s life or limb within twenty- four (24) hours, based upon a reasonable medical certainty

(c) Emergency Medical Evacuation is recommended by the attending Physician who certifies to the matters in subparagraphs (a) and (b), above

(d) Emergency Medical Evacuation is agreed to by the Insured Person or a Relative of the Insured Person

(e) Emergency Medical Evacuation is provided by designated, licensed, qualified, professional emergency personnel acting within the scope of such license and approved in advance and all arrangements are coordinated by the Company

(f) the condition, Illness, Injury or occurrence giving rise to the need for the Emergency Medical Evacuation:

(i) occurred outside the Insured Person’s Country of Residence suddenly, Unexpectedly, and spontaneously, and without: (1) advance warning, or (2) advance Treatment, diagnosis or recommendation for Treatment by a Physician, or (3) prior manifestation of symptoms or conditions that would have caused a reasonably prudent person to seek medical attention prior to the onset of the Emergency

(ii) was not a Pre-existing Condition.

(g) The Company will cover reimbursement for the above-described costs and expenses and will arrange Emergency Medical Evacuation only to the nearest Hospital that is qualified to provide the Medically Necessary Treatment to prevent the Insured Person's loss of life or limb.

The Insured Person may select a different Hospital in their Country of Residence at their option, but in such event the Insured Person shall be solely responsible for all costs and expenses in excess of the amounts that would have been incurred had the Insured Person used the nearest qualified Hospital. If a Hospital other than the nearest qualified Hospital is selected by the Insured Person, then the attending Physician, Insured Person, or a Relative of the Insured Person shall certify to the Company the Insured Person’s understanding and acknowledgement of such responsibility for excess costs and expenses in addition to the matters set forth in the CONDITIONS AND RESTRICTIONS subparagraph, above. In all cases the Company will make the necessary arrangements for the Emergency Medical Evacuation and will use its best efforts to arrange with independent, third-party contractors any Emergency Medical Evacuation within the least amount of time reasonably possible.

By acceptance of this Certificate and request for Emergency Medical Evacuation benefits hereunder, the Insured Person understands, acknowledges and agrees that the timeliness, duration, occurrences during, and outcome of an Emergency Medical Evacuation can be directly and indirectly affected by events and/or circumstances that are not within the supervision or control of the Company, including but not limited to: the availability, limitations, physical condition, reliability, maintenance and training schedules and procedures, and performance or non-performance of competent transportation equipment, supplies and/or staff of such third-party contractors; delays or restrictions on flights or other modes or means of transportation caused by mechanical problems, government officials, telecommunications problems, non-availability of routes, and/or other travel, geographical or weather conditions; and other acts of God and unforeseeable and/or uncontrollable occurrences.

The Insured Person agrees to release and to hold the Company, the Plan Administrator and their agents and representatives harmless from, and agrees that the Company, the Plan Administrator and their agents and representatives shall not be held liable or responsible for, any delays, losses, damages, further Injuries or Illnesses, or any other claims that arise from or are caused in whole or in part by the acts or omissions of such independent third- party contractors or their agents, employees or representatives, or that arise from or are caused in whole or in part by any acts, omissions, events or circumstances that are not within the direct and immediate supervision and control of the Company, the Plan Administrator and/or their authorized agents and representatives, including without limitation the events and circumstances set forth above.

The Insured Person further agrees that upon seeking an Emergency Medical Evacuation, they will cooperate fully as required by the CONDITIONS AND GENERAL PROVISIONS, COOPERATION provision. Failure to so cooperate and/or failure to use or accept Emergency Medical Evacuation once it has been arranged by the Company or Plan Administrator will require the Insured Person to reimburse the Company for costs incurred for any Emergency Medical Evacuation that was arranged, but not used, by the Insured Person. Furthermore, the Insured Person may be required to arrange for payment of any subsequent Emergency Medical Evacuation and seek reimbursement thereafter for eligible costs associated with that subsequent Emergency Medical Evacuation.

K. EMERGENCY REUNION:

(1) Subject to the Terms of this insurance, including without limitation the CONDITIONS AND RESTRICTIONS subparagraph below, Emergency Reunion expenses will be reimbursed to an Insured Person as outlined in the BENEFIT SUMMARY, in cases where there has been an Emergency Medical Evacuation covered under the Terms of this insurance. Subject to the applicable Deductible and Coinsurance and other limits and sub-limits as specified in the BENEFIT SUMMARY, and subject to the CONDITIONS AND RESTRICTIONS subparagraph below, the following costs and expenses incurred in respect of travel by a Relative or friend of the Insured Person will be reimbursable to the Insured Person upon the recommendation and prior approval of the Company:

(a) the cost of a round-trip economy commercial airline ticket for one (1) Relative or friend from the airport nearest to the location of the Relative or friend at the time of the Emergency to the airport serving the area where the Insured Person is Hospitalized as a result of the Emergency or is to be Hospitalized as a result of the Emergency Medical Evacuation (to be determined pursuant to the Terms of the CONDITIONS AND RESTRICTIONS subparagraph, below), and return from whichever of such locations is actually selected to the point of the original departure

(b) reasonable and necessary travel costs, meals (up to the amount shown in the BENEFIT SUMMARY), transportation and accommodation expenses incurred in relation to the Emergency Reunion (but excluding entertainment).

(2) CONDITIONS AND RESTRICTIONS:

(a) the allowable maximum coverage for the Emergency Reunion shall not exceed fifteen (15) days, including travel days, and all costs and expenses incurred beyond such fifteen (15) days shall be retained for the sole account and responsibility of the Insured Person, Relative, or friend

(b) the Emergency Reunion must be due to an Emergency Medical Evacuation covered under the Terms of this insurance

(c) the Insured Person must be so seriously ill that the attending Physician deems it necessary and recommends the presence of a Relative or friend at either the location where the Insured Person is being evacuated from or the destination of the Emergency Medical Evacuation, whichever is considered by the attending Physician and the Company to be the more reasonable

(d) all Emergency Reunion travel, transportation and accommodation arrangements and benefits must be approved in advance by the Company in order to be eligible for coverage under this insurance

(e) the Insured Person, Relative and/or friend must submit to the Company upon completion of the Emergency Reunion travel legible and verifiable copies of all paid receipts for the travel and transportation costs and expenses so incurred for which reimbursement is sought.

INCIDENTAL TRIP: As an accommodation and supplemental benefit and subject to the Terms of this insurance, the Insured Person will be covered under this insurance during incidental return trips to their Country of Residence up to the number of days shown in the BENEFIT SUMMARY during the Period of Coverage beginning with the date the Insured Person first arrives back in their Country of Residence provided that:

(1) the Insured Person has departed their Country of Residence prior to any Incidental Trip

(2) the Insured Person has timely paid applicable Premium for at least thirty (30) days of continuous coverage

(3) the Country of Residence is not the United States

(4) the intention or purpose of the Insured Person’s return trip to the Country of Residence is not to receive Treatment for an Illness or Injury incurred or sustained while traveling outside of their Country of Residence

(5) the Insured Person’s return trip to the Country of Residence does not result in receiving Treatment for an Illness or Injury incurred or sustained while traveling outside of their Country of Residence.

POLITICAL EVACUATION AND REPATRIATION: If the United States Department of State, Bureau of Consular Affairs or similar government organization of the Insured Person’s Country of Residence orders the evacuation of all non-emergency government personnel from the Destination Country, due to political unrest, that becomes effective on or after the Insured Person’s date of arrival in the Destination Country, the Company will reimburse up to the amount shown in the BENEFIT SUMMARY for transportation to the nearest place of safety or for repatriation to the Insured Person’s Country of Residence provided that all of the following conditions are met:

(a) the Insured Person contacts the Company within ten (10) days of the United States Department of State, Bureau of Consular Affairs or similar government organization of the Insured Person’s Country of Residence issuing the evacuation order

(b) the evacuation order pertains to persons from the same Country of Residence as the Insured Person

(d) In no event will the Company pay for a Political Evacuation if there is a Travel Warning or Emergency Travel Advisory in effect on or within six (6) months prior to the Insured Person’s date of arrival in the Destination Country. This coverage will provide the most appropriate and economical means of travel consistent under the circumstances of the Insured Person’s health and safety.

PUBLIC HEALTH EMERGENCY: Subject to all other Terms of this insurance, in the event of a Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster, that may affect an Insured Person’s health, the Company will cover an Illness or Injury incurred during the Period of Coverage and caused by the Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster when, prior to the issuance of a Travel Warning for the Destination Country or a Global Travel Warning:

(1) the Effective Date of Coverage has occurred; and

(2) the Insured Person has arrived in the Destination Country or Affected Area.

In the event that the applicable Travel Warning is removed for the Destination Country or Affected Area, coverage for an Illness or Injury incurred during the Period of Coverage after the Travel Warning is removed, which was caused by the Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster will be considered by the Company the same as any other Illness or Injury, subject to all other Terms and conditions of this insurance.

Notwithstanding the above provisions of this section PUBLIC HEALTH EMERGENCY, COVID-19/SARS-CoV-2 shall be considered by the Company the same as any other Illness or Injury, subject to all other Terms and conditions of this insurance.

REPATRIATION FOR MEDICAL TREATMENT: Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision the Company will reimburse the Insured Person for costs incurred during the Period of Coverage to repatriate the Insured Person back to their Country of Residence.

The Company reserves the right to review and repatriate any case in which the Insured Person is medically stable and the attending Physician certifies the Insured Person can be evacuated at the Company’s discretion to the Insured Person’s Country of Residence and any form of Treatment or Surgery which in the same medical opinion can be delayed until the Insured Person returns to their Country of Residence. The Insured Person’s refusal to accept repatriation when medically stabilized can result in the Company denying further medical coverage and benefits. The Company will make the necessary arrangements to repatriate the Insured Person to their Country of Residence and will use its best efforts to arrange with independent, third-party contractors for the Repatriation for Medical Treatment within the least amount of time reasonably possible.

RETURN OF MORTAL REMAINS: In the event of the death of the Insured Person during the Period of Coverage as a result of an Illness or Injury covered under this insurance while the Insured Person is outside of their Country of Residence, the Company will reimburse the authorized personal representative or the estate of the Insured Person up to the amount shown in the BENEFIT SUMMARY for the costs and expenses incurred to return the Insured Person's Mortal Remains to their Country of Residence and thereafter to the place of burial or other final disposition (but not including any costs of burial or other disposition); provided, however, that the Company must approve all costs and expenses related to the return of the Insured Person's Mortal Remains in advance as a condition to the availability of this benefit; or up to the amount shown in the BENEFIT SUMMARY 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 practitioners, flowers, music, food or beverages.

Exclusion

CORONAVIRUS (COVID-19/SARS-CoV-2) ENDORSEMENT

Attaching to and forming part of the Master Policy, as evidenced by the Certificate of Insurance, and subject to all other Terms and conditions of the Master Policy, the following changes are effective July 1, 2020.

The following provision is added:

PUBLIC HEALTH EMERGENCY: Subject to all other Terms of this insurance, in the event of a Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster, that may affect an Insured Person’s health, the Company will cover an Illness or Injury incurred during the Period of Coverage and caused by the Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster when, prior to the issuance of a Travel Warning for the Host Country/Destination Country or a Global Travel Warning:

1) the Effective Date of Coverage has occurred; and

2) the Insured Person has arrived in the Host Country/Destination Country or Affected Area.

In the event that the applicable Travel Warning is removed for the Host Country/Destination Country or Affected Area, coverage for an Illness or Injury incurred during the Period of Coverage after the Travel Warning is removed, which was caused by the Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster will be considered by the Company the same as any other Illness or Injury, subject to all other Terms and conditions of this insurance.

COVID-19/SARS-CoV-2 is not applicable to this provision.

The following is added to the ELIGIBLE MEDICAL EXPENSES provision:

Charges for Treatment resulting from COVID-19/SARS-CoV-2

The following is deleted in its entirety from the EXCLUSIONS provision:

any Illness or Injury incurred in the Host Country/Destination Country as a result of epidemics, pandemics, public health emergencies, Natural Disasters, or other disease outbreak conditions that may affect a person’s health when, prior to the Insured Person’s entry into the Host Country/Destination Country, any of the following were issued regarding the Host Country/Destination Country:

(a) the World Health Organization had issued a Travel Warning or Emergency Travel Advisory

(b) the United States Centers for Disease Control & Prevention had issued a Warning Level 3 (avoid nonessential travel)

(c) a similar governmental agency of the Insured Person’s Home Country/Country of Residence had published, communicated or issued a Travel Warning or Emergency Travel Advisory restriction or official declaration informing the public about such health issues before the Insured Person traveled to the Host Country/Country of Residence

and replaced with:

any Illness or Injury incurred in the Host Country/Destination Country, Affected Area or Home Country/Country of Residence as a result of a Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster, that may affect an Insured Person’s health, unless coverage is expressly provided under the PUBLIC HEALTH EMERGENCY provision of this insurance

This exclusion DOES NOT apply to Charges resulting from COVID-19/SARS-CoV-2.

The following defined Terms are added to the DEFINITIONS provision:

Affected Area(s): Any and all countries, states, provinces, territories, cities or other areas experiencing ongoing transmission of an Epidemic, Pandemic or other disease outbreak, or Natural Disaster.

Epidemic: The occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time.

Global Travel Warning: A published statement, warning or advisory, including any website document, issued by the World Health Organization (WHO), United States Centers for Disease Control & Prevention (CDC), United States Department of State, United States Bureau of Consular Affairs, or similar government or non-governmental agency of the Insured Person’s Home Country/Country of Residence or Host Country/Destination Country, warning that any global travel (travel anywhere) poses serious risks to health, safety and security or exposes the Insured Person to a greater likelihood of life-threatening risks, including all United States Department of State global advisories or global warnings Levels “3 - reconsider travel” and “4 -do not travel” and CDC global advisories or global warnings Level “3 – avoid nonessential travel” or any higher level. For the avoidance of doubt, a Global Travel Warning covers all Affected Areas, including the United States of America and all of its territories.

Natural Disaster: Widespread disruption of human lives by disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm, or other storm, landslide, or other natural catastrophe or event resulting in migration of the human population for its safety. The occurrence must be a disaster that is due entirely to the forces of nature and could not reasonably have been prevented.

Pandemic: A global outbreak of a disease.

Public Health Emergency of International Concern: A formal declaration by the World Health Organization (WHO) of an extraordinary event which is determined to constitute a public health risk through the international spread of disease, Epidemic, Pandemic and potentially requires a coordinated international response.

Travel Warning; Emergency Travel Advisory: A published statement, warning or advisory, including any website document, issued by the World Health Organization (WHO), United States Centers for Disease Control & Prevention (CDC), United Stated Department of State, United States Bureau of Consular Affairs, or similar government or non-governmental agency of the Insured Person’s Home Country/Country of Residence or Host Country/Destination Country, warning that travel to Affected Areas poses serious risks to health, safety and security or exposes the Insured Person to a greater likelihood of life-threatening risks, including all United States Department of State Travel Advisories or Warnings Levels “3 - reconsider travel” and “4 -do not travel” and CDC Travel Advisories or Warnings Level “3 – avoid nonessential travel” or any higher level. For the avoidance of doubt, a Travel Warning covers all specified Affected Areas, including the United States of America as applicable.

Except as expressly provided for in the Schedule of Benefits/Limits, all charges, costs, expenses and/or claims (collectively “Charges”) incurred by the Insured Person and any claim for death or dismemberment benefits directly or indirectly relating to or arising or resulting from or in connection with any of the following acts, omissions, events, conditions, charges, consequences, claims, Treatment (including diagnoses, consultations, tests, examinations and evaluations related thereto), services and/or supplies are expressly excluded from coverage under this insurance, and the Company shall provide no benefits or reimbursements and shall have no liability or obligation for any coverage thereof or therefor:

(1) War; Military Action – Subject to the Terms of Section F.(5), above, and Section N.(2), below, the Company shall not be liable for and will not provide coverage or benefits for any claim or Charges incurred with respect to any Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising or incurred in connection with or as a result of any of the following acts or events (collectively, "Occurrences"):

war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war;
mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power;
any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by violence of any type;
martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege; and
any use of radiological, chemical, nuclear or biological weapons or any other radiological, chemical, nuclear or biological events of any type (including in connection with an act of Terrorism).

Any claim, Charges, Illness, Injury or other consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether or not directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Occurrences shall be deemed and considered to be consequences for which the Company shall not be liable under the Master Policy or this Certificate, except to the extent that the Insured Person shall prove that such claim, Charges, Illness, Injury or other consequence happened independently of the existence of such abnormal conditions and/or Occurrences.

(2) Terrorism – The Company shall not be liable for and will not provide coverage or benefits in excess of a $50,000 lifetime maximum benefit for any claim or charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with any act of Terrorism; and provided, further, the Company shall not be liable for and will not provide any coverage or benefits for any claim, charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with the following:

the Insured Person's active and voluntary planning or coordination of or participation in any act of Terrorism; and/or
any act of Terrorism that takes place in a location, post, area, territory or country for which the United States Department of State, Bureau of Consular Affairs issued a Travel Warning that was in effect on or within six (6) months prior to the Insured Person's date of arrival in said location, post, area, territory or country; and/or
any act of Terrorism that takes place in a location, post, area, territory or country for which the United States Department of State, Bureau of Consular Affairs issues a Travel Warning that becomes effective or is in effect on or after the Insured Person's date of arrival in said location, post, area, territory or country, and the Insured Person unreasonably fails or refuses to heed such warning and thereafter remains in said location, post, area, territory or country.

(3) Pre-existing Conditions – Charges arising or resulting directly or indirectly from or relating to any Pre-existing Condition, as herein defined, subject to the Terms of Section L., above; and

(4) Maternity and Newborn Care – Charges for pre-natal care, delivery, post-natal care, and care of Newborns, including complications of Pregnancy, miscarriage, complications of delivery and/or complications of Newborns; and

(5) Charges for Treatment of Mental or Nervous Disorders; and

(6) Charges for any Treatment or supplies that are:

not incurred, obtained or received by an Insured Person during the Period of Coverage; and/or
not presented to the Company for payment by way of a complete Proof of Claim within ninety (90) days of the date such Charges are incurred; and/or
not administered or ordered by a Physician; and/or
not Medically Necessary; and/or
provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable; and/or
in excess of Usual, Reasonable, and Customary; and/or
incurred by an Insured Person who was HIV + on or before the Effective Date of this insurance relating to or arising or resulting directly or indirectly from HIV, AIDS virus, AIDS related Illness, ARC Syndrome, AIDS and/or any other Illness arising or resulting from any complications or consequences of any of the foregoing conditions; whether or not the Insured Person had knowledge of his/her HIV status prior to the Effective Date, and whether or not the Charges are incurred in relation to or as a result of said status; and/or
provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician; and/or
performed or provided by a Relative of the Insured Person; and/or
not expressly included as Eligible Medical Expenses as defined in Section F., above; and/or
provided by a person who resides or has resided with the Insured Person or in the Insured Person's home; and/or
required or recommended as a result of complications or consequences arising from or related to any Treatment, Illness, Injury, or supply excluded from coverage or which is otherwise not covered under this insurance; and
for Congenital Disorders and conditions arising out of or resulting therefrom; and

(7) Charges incurred for telephone consultations except Telemedicine consultations through an established Telemedicine protocol system will be considered individually based on medical necessity and appropriateness as determined by the Company under the plan; and

(8) Charges incurred due to a failure to keep a scheduled appointment; and

(9) Charges incurred for Surgeries or Treatment or supplies which are:

Investigational, Experimental, or for research purposes, and/or
related to genetic medicine, genetic testing, surveillance testing and/or wellness screening procedures for genetically predisposed conditions indicated by genetic medicine or genetic testing, including, but not limited to amniocentesis, genetic screening, risk assessment, preventive and prophylactic surgeries recommended by genetic testing, and/or any procedures used to determine pre-disposition, provide genetic counseling, or administration of gene therapy; and

(10) Charges incurred while confined primarily to receive Custodial Care, Educational or Rehabilitative Care; and

(11) Charges incurred for any Surgery, Treatment or supplies relating to, arising from or in connection with, for, or as a result of:

weight modification or any Inpatient, Outpatient, Surgical or other Treatment of obesity (including without limitation morbid obesity), including without limitation wiring of the teeth and all forms or procedures of bariatric Surgery by whatever name called, or reversal thereof, including without limitation intestinal bypass, gastric bypass, gastric banding, vertical banded gastroplasty, biliopancreatic diversion, duodenal switch, or stomach reduction or stapling; and/or
modification of the physical body in order to change or improve or attempt to change or improve the physical appearance or psychological, mental or emotional well-being of the Insured Person (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof); and/or
elective Surgery or Treatment of any kind; and/or
cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and follows a Surgery which was covered under this insurance; and/or
any Illness or Injury sustained while taking part in: Amateur Athletics, Professional Athletics, or other athletic activity that is sponsored or sanctioned by the National Collegiate Athletic Association (and/or any other collegiate sanctioning or governing body), or the International Olympic Committee, and adventure sports and activities, including, without limitation the following (including any combination or derivative of the following): abseiling; mountaineering activities where specialized climbing equipment, ropes or guides are normally or reasonably should have been used; athletic or sporting activities (except for activities that are non-contact, non-professional, and engaged in by You solely for recreational, entertainment or fitness purposes); aviation (except when travelling solely as a passenger in a commercial aircraft); motocross (MOTO-X); BMX; BASE jumping; bobsledding; bungee jumping; canyoning; caving; hang gliding; heli-skiing; high diving; hot air ballooning; inline skating; jet skiing; jungle zip lining; kiteboarding; kayaking; luge; mountain biking; parachuting; paragliding; parascending; rappelling; racing of any kind including without limitation by horse, motor or other vehicle (of any type) or motorcycle; rock climbing; any rodeo activity; ski jumping; sky diving; snow skiing except for recreational downhill and/or cross country snow skiing (provided that there is no coverage for any Illness of Injury sustained while skiing in violation of applicable laws, rules or regulations; away from prepared and marked in-bound territories; and/or against the advice of the local ski school or local authoritative body); snowboarding; snowmobiling; spelunking; surfing; trekking; whitewater rafting; windsurfing; wildlife safaris; and sub-aqua pursuits involving underwater breathing apparatus below a depth of 10 meters. Practice or training in preparation for any excluded activity which results in Illness or Injury will be considered as activity while taking part in such activity; and/or
any Illness or Injury sustained while participating in any sporting, recreational or adventure activity where such activity is undertaken against the advice or direction of any local authority or any qualified instructor or contrary to the rules, recommendations and procedures of a recognized governing body for the sport or activity; and/or
any Illness or Injury sustained while participating in any activity where such activity is undertaken in disregard of or against the recommendations, Treatment programs, or medical advice of a Physician or other healthcare provider; and/or
any Injury or Illness sustained as a result of being under the influence of or due wholly or partly to the effects of alcohol, liquor, intoxicating substance, narcotics or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician but not for the Treatment of Substance Abuse; and/or
any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician. For purposes of this exclusion, "vehicle" shall include motorized devices regardless of whether or not a driver or operator license is required (including watercraft and aircraft) and non-motorized bicycles and scooters for which no permit or license is required; and/or
any willfully Self-inflicted Injury or Illness; and/or
any sexually transmitted or venereal disease; and/or
any testing for the following: HIV, seropositivity to the AIDS virus, AIDS related Illnesses, ARC Syndrome, AIDS; and/or
any Illness or Injury resulting from or occurring during the commission of a violation of law by the Insured Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations; and/or
any Substance Abuse; and/or
speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy; and/or
orthoptics, visual therapy or visual eye training; and/or
any Illness or Treatment of the feet, including without limitation: orthopedic shoes; orthopedic prescription devices to be attached to or placed in shoes; Treatment of weak, strained, flat, unstable or unbalanced feet; metatarsalgia, bone spurs, hammer toes or bunions; and any Treatment or supplies for corns, calluses or toenails; provided, however, that claims for Treatment or supplies for the feet may be eligible for coverage under this insurance at the sole option of the Company and subject to all other

Terms of this insurance when related to:

an Injury to the foot arising from an Accident covered hereunder; or
an Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of Treatment; and/or
hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician; and/or
any sleep disorder, including without limitation sleep apnea; and/or
any exercise program, whether or not prescribed or recommended by a Physician; and/or
any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s); and/or
any organ or tissue or other transplant or related services, Treatment or supplies; and/or
any artificial or mechanical devices designed to replace human organs temporarily or permanently; and/or
any efforts to keep a donor alive for a transplant procedure; and/or

(12) Charges incurred for any Treatment or supply that either promotes or prevents or attempts to promote or prevent conception or birth; including but not limited to: artificial insemination; oral contraceptives, Treatment for infertility or impotency; vasectomy or reversal of vasectomy; sterilization or reversal of sterilization; surrogacy or abortion; and

(13) Charges incurred for any Treatment or supply that either promotes, enhances or corrects or attempts to promote, enhance or correct impotency or sexual dysfunction; and

(14) Charges incurred for Dental Treatment;

(15) Charges incurred for eyeglasses, contact lenses, hearing aids, hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason; and

(16) Charges incurred for eye Surgery, such as but not limited to radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness, or astigmatism; and

(17) Charges incurred in the Insured Person's Home Country, except as expressly provided for in this insurance; and

(18) Charges incurred outside the Coverage Area as indicated in Section C. Schedule of Benefits/Limits; and

(19) Charges incurred for any immunizations and/or Routine Physical Exams; and

(20) Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance; and

(21) Any taxes, involuntary or forced contributions, assessments, charges, fees or surcharges imposed by any governmental agency or authority:

arising out of or as a result of any Treatment or supplies received by the Insured Person, or
based upon the Company's election hereunder, if any, to pay benefits directly to providers as an accommodation to the Insured Person, or
for any other reason; and

(22) Charges or expenses incurred for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; drugs or medicines not approved by the U.S. Food and Drug Administration or which are considered "off-label" drug use; and for drugs or medicines not prescribed by a Physician.

(23) Charges and all costs related to or arising from or in connection with all trips to the Host Country undertaken for the purpose of securing medical Treatment or supplies; and

(24) Charges incurred for hospice care.

(25) Accidental Death or Dismemberment when the Insured Person’s death or dismemberment is caused directly or indirectly by, results from, or where there is a contribution from, any of the following:

bodily or mental infirmity, illness or disease; or
infection, other than infection occurring simultaneously with, and as a direct result of, the accidental injury.

Acute Pre-Ex Coverage

If condition existed within thirty-six (36) months prior to Effective Date, Charges are excluded until after twelve (12) months of coverage and then $500 Maximum Limit Per Period of Coverage and $50,000 Maximum Limit per lifetime.

Subject to the Terms of this insurance, including without limitation the Exclusions set forth in Section N., the Conditions and Restrictions set forth below and the applicable Deductible and Coinsurance and other limits and sub-limits as specified in the Schedule of Benefits/Limits set forth in Section C., above, inthe event the Insured Person suffers or experiences an Unexpected recurrence of a Pre-existing Condition during the Period of Coverage for which immediate Treatment is essential and necessary to stabilize the Pre-existing Condition, the Insured Person will be reimbursed up to US$5,000 (not to exceed $5,000 Lifetime Maximum) for Eligible Medical Expenses incurred during the Period of Coverage with respect to the Unexpected recurrence of the Pre-existing Condition.

Conditions and Restrictions - To be eligible for the foregoing limited coverage and benefits for an Unexpected recurrence of a Pre-existing Condition, the Insured Person must be a U.S. citizen and must be in compliance with all Terms of this insurance. The Company will provide such coverage and benefits only when all of the following conditions and restrictions have been met. At the time of the Unexpected recurrence of the Pre-existing Condition:

The Insured Person must not be traveling against or in disregard of the recommendations, established Treatment programs, or medical advice of a Physician or other healthcare provider; and
The Insured Person must not be traveling with the intent or purpose to seek or obtain Treatment for the Pre-existing Condition; and
The Insured Person must not be traveling during a period of time when the Insured Person is preparing or waiting for, involved in, or undertaking a new, changed or modified Treatment program with respect to the Pre-existing Condition, and is not traveling subsequent to any such new, changed or modified Treatment program having been advised or recommended; and
The Pre-existing Condition must have been stabilized for at least thirty (30) days prior to the Effective Date without change in Treatment; and
The Insured Person must be traveling outside the Home Country.

PPO Network

The Company, through the Plan Administrator, endeavors to maintain a contractual arrangement with one or more independent Preferred Provider Organizations (PPO) that has established and maintains a network of U.S.-based Physicians, Hospitals and other healthcare and health service providers who are contracted separately and directly with the PPO and who may provide re-pricings, discounts or reduced charges for Treatment or supplies provided to the Insured Person. Neither the Company nor the Plan Administrator has any authority or control over the operations or business of the PPO, or over the operations or business of any provider within the independent PPO network. Neither the PPO nor provider within the PPO network nor any of their respective agents, employees or representatives has or shall have any power or authority whatsoever to act for or on behalf of the Company or the Plan Administrator in any respect, including without limitation no power or authority to: (i) approve Applications or enrollments for initial, renewal or reinstated coverage under this insurance plan or to accept Premium payments, (ii) accept risks for or on behalf of the Company, (iii) act for, speak for, or bind the Company or the Plan Administrator in any way, (iv) waive, alter or amend any of the Terms of the Master Policy or this Certificate or waive, release, compromise or settle any of the Company’s rights, remedies, or interests thereunder or hereunder, or (v) determine Pre-certification, eligibility for coverage, verification of benefits, or make any coverage, benefit or claim adjudications or decisions of any kind. It is not a requirement of this insurance that the Insured Person seek Treatment or supplies exclusively from a provider within the independent PPO network. However, the Insured Person’s use or non-use of the PPO network may affect the scope and extent of benefits available under this insurance, including without limitation any applicable Deductible, Coinsurance and benefit reduction, as set forth above. An Insured Person may contact the Company through the Plan Administrator and request a PPO Directory for the area where the Insured Person will be receiving consultation or Treatment (therein listing the Physicians, Hospitals and other healthcare providers within the PPO network by location and specialty), or may visit the Plan Administrator’s website at http://myimglobal.com to obtain such information.

Click here for PPO Network

Renew

Subject to the Terms of the Termination of Master Policy and Termination of Coverage for Insured Persons sections, an Insured Person whose initial Period of Coverage is at least one (1) month can request coverage under this insurance plan to be renewed a minimum of five (5) days until reaching a maximum of forty-eight (48) continuous months in accordance with and subject to the Terms of the plan then in effect (including the Terms of the then applicable Master Policy) and so long as renewal Premium is paid when due and the Insured Person otherwise continues to meet the applicable eligibility requirements of the plan.

The Company’s commitment and the Insured Person’s ability to renew is also subject to termination upon thirty (30) days written notice to the other party prior to the expiration date of the then existing Period of Coverage. The Company reserves the right in its sole discretion to make changes, additions and/or deletions to the Terms of the Master Policy, this Certificate, renewals or replacements of either, and/or to the insurance plan (including the issuance of Riders to effectuate same) at any time or from time to time after the Effective Date of Coverage of this Certificate, upon no less than ninety (90) days prior written notice to the Assured and the Insured Person (“Notice of Amendment”). The Notice of Amendment shall include a complete description of the changes, additions and/or deletions to be made, the effective date thereof (the “Change Date”), and notice of the Insured Person’s cancellation rights as set forth below, and shall be sent first class mail, postage pre-paid, to the last known residence or mailing address of the Insured Person. Upon issuance of the Notice of Amendment, the Assured and/or the Insured Person shall have the right to request cancellation of this Certificate above, at any time prior to the Change Date; provided, however that cancellation under this section shall be at the option of the Insured Person, and coverage under this insurance shall terminate with effect from the cancellation date specified by the Insured Person (subject to the provisions of the Termination of Coverage for Insured Persons section. If the Insured Person does not elect to cancel this Certificate in accordance with the foregoing, the changes, additions and/or deletions as made by the Company and specified in said Notice of Amendment shall take effect as of the Change Date specified in the Company’s Notice, and this insurance shall thereafter continue in effect in accordance with its Terms, as so amended and modified.

Online Form

Cancel

CANCELLATION BY INSURED PERSON: The Insured Person shall have three (3) days from the Initial Effective Date of Coverage (the “Review Period”) to review the benefits, conditions, limitations, exclusions and all other Terms of the Master Policy as evidenced and outlined by this Certificate. If not completely satisfied, the Insured Person may request cancellation of this insurance retroactive to the Initial Effective Date of Coverage by sending a written request to the Company by email, mail or fax and received by the Company within the Review Period, thereby qualifying to receive a full refund of Premium paid. Upon effectuation of such cancellation and refund, neither the Company nor the Insured Person shall have any further rights, liabilities or obligations under this insurance. After the Review Period, the Insured person may request cancellation by sending a written request to the Company by email, mail or fax. However, the following conditions apply for Premium refund:

(a) If any claims have been filed with the Company, the Premium is fully earned and is non-refundable.

(b) If no claims have been filed with the Company:

(i) a cancellation fee of fifty dollars ($50.00 USD) will be charged; and

(ii) only Premium covering time periods after cancellation are refundable; and

(iii) only full month Premiums are refundable.

Claim

CLAIMS NOTIFICATION: All claims and related claim information should be filed with the Company through the Plan Administrator at the contact information below, or online at www.imglobal.com/member as soon as possible:

International Medical Group Attn: Claims Department PO Box 9162

Farmington Hills, MI 48333-9162 USA

Proof of Claim: When the Insured Person receives Treatment or the Company receives notice of a claim for benefits under this insurance, the Insured Person shall submit an International Medical Group (IMG) Claim Form as a necessary component of the Proof of Claim. An IMG Claim Form may be obtained from the form’s library on IMG’s website at www.imglobal.com or completed online via the MyIMG customer portal.

(a) A Proof of Claim shall not be effective and will not satisfy the Terms of this insurance unless it includes all the following:

(i) a duly completed, timely submitted and signed IMG Claim Form for each new Illness, diagnosis or Injury unless the Company waives such requirement in writing

(ii) an Authorization for Release of Medical Information when specifically requested by IMG

(iii) all original Universal Billing Forms, Superbill and statements of service rendered from Physicians, Hospitals, and other healthcare or medical service providers involved with respect to the claim

(iv) all original receipts for any costs, prescription medications, fees or expenses that have been incurred or paid by, or on behalf of, the Insured Person with respect to the claims, including without limitation all original receipts for any cash and/or credit card payments. The provider of service’s full name, address, telephone number (including area/country code), date of service, description of service (applicable procedure codes), and diagnosis codes must be included on the receipts.

(v) If the claims are submitted electronically, copies of the above items are acceptable; however, the Company reserves the right to request the original documents.

(b) The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have one hundred eighty (180) days from the date a claim is incurred to submit a complete Proof of Claim. The Company at its option may pend resolution and adjudication of submitted claims and/or may deny coverage due to any of the following:

(i) IMG’s receipt of an incomplete Proof of Claim

(ii) failure to submit any Proof of Claim

(iii) Insured Person’s, Physician’s or Hospital’s failure to submit a timely Proof of Claim

(c) The Company may require the Insured Person to sign an Authorization for Release of Medical Information to request medical records on their behalf or supply us with additional documentation if we are unable to make a benefit determination based on the submitted Proof of Claim. The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have sixty (60) days from the date of the request to submit the requested information. If the information is not received within the designated time period, previously submitted and subsequent claims will be denied.

APPEALING A CLAIM: In the event the Company denies all or part of a claim, the Insured Person shall have ninety (90) days from the date that the notice of denial was mailed to the Insured Person's last known residence or mailing address within which to appeal the determination. The Insured Person must file an appeal prior to bringing any legal action under the contract of insurance. The Insured Person should submit a written request for an appeal along with comments, all relevant, pertinent or related documents, medical records, and other information relating to the claim.

The appeal must be sent to:

International Medical Group Attn: Benefit Review

2960 N. Meridian Street Indianapolis, IN 46208 USA

The Company’s review will take into account all comments, documents, records, and other information submitted by the Insured Person relating to the claim, without regard to whether such information was submitted or considered in the initial claim determination. Upon receipt of a written appeal, the Company shall have an opportunity for further reasonable investigation and/or review as set forth in the CONDITIONS AND GENERAL PROVISIONS, EXPLANATION OR VERIFICATION OF BENEFITS provision, and will respond in writing as soon as reasonably practicable, and in any event within ninety (90) days from receipt thereof.

APPEAL PROCESS: If the Insured Person disagrees with a Pre-certification decision of the Company, the Insured Person may in writing ask the Company to reconsider the decision and may supply additional documentation to support the appeal. The Company may reconsider its decision based on review of the additional documentation and facts, if any. The Company will advise the Insured Person of its decision within a reasonable time frame following receipt of additional documentation and facts.

The appeal must be sent to AkesoCare:

Phone: +1.317.655.4500, Option #2

Fax: +1.317.655.4505: ATTN: AkesoCare - Appeals Email: ACM@akesocare.com

Scenario	Coverage Under Full Pre-Existing Plan
My father had a heart attack a few years ago. After his travel to the US, he started experiencing heart pain. I took him to the cardiologist. Is this covered?	Yes. Cardiologist visits are covered underneath a Full Pre-Existing coverage plan.
My mother-in-law has been experiencing heart pain for last few days, and had a heart attack on the last day. Is this covered?	Yes. Under a Full Pre-Existing Plan, there is not time limitation between symptoms and seeking care.
My uncle had cancer a few years ago. He is on a Green Card and has been living in the US. Recently, the cancer has come back. Is this covered?	Yes. Chemotherapy & Radiation treatment are covered under this plan. One note- the recurring cancer diagnosis must occur after the effective date.
My cousin had a back injury a few years back. He recently starting feeling back pain and went to seek the advise of a Chiropractor & get physical therapy. Is this covered?	Yes. Chiropractic care & physical therapy regarding pre-existing conditions are covered underneath full pre-existing plans.
My aunt had a sudden heart attack. After staying a few days in the hospital, she needs prescription drugs, follow up blood tests, and doctors visits. Are these covered?	Yes. Any sudden medical event, along with any follow up visits, i.e. blood tests, x-rays, EKG, etc., will be covered by full pre-existing plans.
My mother is diabetic. She was prescribed medication but often forgets to take it often. She experienced a diabetic shock and needed to visit the emergency room. Will this emergency visit be covered?	Yes. Our plans cover you no matter whether your visitor was taking their prescribed medication or not. Full pre-existing plans will cover no matter what happens.

Scenario	Coverage Under INF Acute Onset Plan
My father had a heart attack a few years ago. After his travel to the US, he started experiencing heart pain. I took him immediately to the emergency room. Is this covered?	Yes. Cardiologist visits are covered underneath a Full Pre-Existing coverage plan.
My mother-in-law had a sudden drop in blood sugar. I took her to the Urgent Care clinic. Is this covered?	Yes, as long as you seek medical attention within 12 hours you are covered.
My uncle was playing a game of cricket in the neighborhood and started to experience chest pain. He was hospitalized for 3 days and required several blood tests, and heart scans. Will this be covered?	Yes. Our plans will cover any sudden recurrence caused by a pre-existing conditions. Our plans have no pre-authorization, meaning the hospital can get the treatment your visitors needs faster.
My father-in-law had several kidney issues over the past few years. After several hours of pain, we took him to the hospital to have kidney stones removed. Is this covered?	Yes. As long as the treatment is sought within the first 12 hours of first exhibiting symptoms, any pre-existing condition will be covered. Our plans have no look back period for pre-existing conditions.
My cousin has diabetes. After a few days in the US, she contracted a Urinary Tract Infection which required hospitalization. Is this covered?	Yes. Under our plans, Urinary Tract Infections are considered new sicknesses and are covered by Acute Onset coverage plans.
My mother is a heart patient. She was prescribed medication but often forgets to take it often. She experienced a sudden heart attack and needed to visit the emergency room. Will this emergency visit be covered?	Yes, our plans cover any incident regardless if your visitor was taking their prescribed medication.