Outreach Group Travel
The following condition applies to all persons applying for and/or enrolling in Outreach Group Travel Medical Insurance.
- Outreach Group Travel Medical Insurance is travel insurance for U.S. citizens traveling outside the United States, and for non-U.S. citizens traveling outside the U.S. and their home country.
- Eligibility to purchase, extend or renew this product, or its terms and conditions, may be modified or amended based upon changes to applicable law, including the Patient Protection and Affordable Care Act (PPACA).
|Coinsurance - for treatment received outside the U.S. & Canada||No Coinsurance|
|Coinsurance - for treatment received within the U.S. & Canada||
In the PPO Network - The plan pays 90% of eligible expenses up to $5,000, then 100% up to the Maximum Limit
Out of the PPO Network - The plan pays 80% of eligible expenses up to $5,000, then 100% up to the Maximum Limit
|Benefit Period||Six months|
|My IMG||24 hour secure access from anywhere in the world to man-age your account at anytime.|
|World-class Medical Benefits||Coverage available for in-patient and out-patient medical expenses|
|International Emergency Care||A wide range of international emergency benefits available including emergency evacuation, emergency reunion, return of mortal remains, return of minor children and more|
Usual, reasonable and customary charges. Subject to deductible and coinsurance when applicable.
|Hospital Room and Board||Up to the Maximum Limit for average semi-private room rate|
|Intensive Care||Up to the Maximum Limit|
|Intensive Care||Up to the Maximum Limit|
|Medical Expenses||Up to the Maximum Limit|
|Out-patient Medical Expenses||Up to the Maximum Limit|
|Local Ambulance||Up to the Maximum Limit|
|Prescription Drugs||Up to the Maximum Limit|
|Emergency Room Accident||Up to the Maximum Limit|
|Emergency Room Illness with In-patient Admission||Up to the Maximum Limit with additional $250 deductible|
|Emergency Room Illness without In-patient Admission||Up to the Maximum Limit|
|Dental - Injury Due to Accident||Up to the Maximum Limit|
|Dental - Sudden Dental Emergency||Up to $100|
|Hospital Daily Indemnity||Up to $100 per night up to a maximum of 10 days|
|INTERNATIONAL EMERGENCY CARE
When coordinated through the Plan Administrator.
|Emergency Medical Evacuation||Up to $500,000 lifetime maximum (independent of the Maximum Limit)|
|Emergency Reunion||Up to $50,000|
|Return of Mortal Remains or Cremation/Burial||Up to $50,000 for Return of Mortal Remains or $5,000 for Cremation/Burial|
|Return of Minor Children||Up to $50,000|
|Political Evacuation||Up to $10,000|
|Natural Disaster||$100 per day for five days|
|Identity Theft Assistance||Up to $500 per Period of Coverage|
When coordinated through the Plan Administrator.
|Terrorism||Up to $50,000 lifetime maximum|
|Sports & Activities Coverage||Up to the Maximum Limit for basic sports|
|Sudden and Unexpected Recurrence of a Pre-existing Condition - Medical (for U.S. citizens only)||Up to age 65 with primary health plan: URC up to plan maximum. Up to age 65 without primary health plan: $20,000 lifetime maximum. Age 65+: $2,500 life-time maximum|
|Sudden and Unexpected Recurrence of a Pre-existing Condition - Medical (for Non-US citizens only)||Up to age 65: $50,000 lifetime maximum for eligible medical expenses. Age 65+: $2,500 lifetime maximum|
|Sudden and Unexpected Recurrence of a Pre-existing Condition - Emergency Medical Evacuation||Up to $25,000 of eligible costs and expenses|
|Incidental Home Country Coverage||Up to a cumulative two weeks|
|End of Trip Home Country Coverage||One month for every five months of travel coverage purchased, up to a maximum of two months|
|Trip Interruption||Up to $5,000|
|Common Carrier Accidental Death||$50,000 to beneficiary; maximum of $250,000 per family|
|Accidental Death & Dismemberment||$25,000 principle sum|
|Lost Luggage||Up to $50 per item of personal property; maximum of $25|
Charges for certain services, treatments and/or conditions, among others, are excluded from coverage under the Outreach Group plan and include but are not limited to:
1. A Pre-existing Condition which is any injury, illness, sickness, disease, or other physical, medical, mental or nervous disorder, condition or ailment that, with reasonable medical certainty, existed at the time of application or at any time during the three years prior to the effective date of the insurance, whether or not previously manifested, symptomatic or known, diagnosed, treated, or disclosed to the Company prior to the effective date, and including any and all subsequent, chronic or recurring complications or consequences related thereto or resulting or arising therefrom.
2. Treatment or surgeries which are elective, investigational, experimental or for research purposes.
3. War, military action, terrorism, political insurrection, protest, or any act thereof. The Company will not pay for a Political Evacuation if there is a travel advisory in effect on or within six (6) months prior to the Insured Person’s date of arrival in the Host Country.
4. Immunizations and routine physical exams.
5. Treatment of Temporomandibular Joint or dental treatment, except as expressly provided for in the Certificate of Insurance.
6. Venereal disease, AIDS virus, AIDS related illness, ARC Syndrome, or AIDS, and the cost of testing for these conditions, and charges for treatment or surgeries which are incurred by any Insured who was HIV+ at time of enrollment into this insurance.
7. Pregnancy, childbirth, birth control, artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion.
8. 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. The following Adventure Sports are excluded unless the Adventure Sports Rider is purchased: abseiling, BMX, bobsledding, bungee jumping, canyoning, caving, hang gliding, heli-skiing, high diving, hot air ballooning, inline skating (with proper use of helmet and pads), jet skiing, jungle zip lining, kayaking, mountain biking, parachuting, paragliding, parascending, piloting a non-commercial aircraft, rappelling, rock climbing or mountaineering (ropes and guides to 4500m from ground level), scuba diving (to 50m), skydiving, snowboarding, snowmobiling, snow skiing, spelunking, surfing, trekking, whitewater rafting (to Class V), wildlife safaris, and windsurfing. All such activities must be carried out in strict accordance wit the rules, regulations and guidelines of the applicable Governing Body or Authority of each such activity. Injury sustained while participating in contact sports of any kind, racing of any kind, any rodeo activity, BASE jumping, kiteboarding, mountaineering or climbing or trekking above elevation 4500 meters above ground level or without proper ropes or guides; luge, motocross, Moto-X, ski jumping, sub-aquatic activities below 50 meters, whitewater rafting exceeding Class V difficulty; and/or adventure sports activity not expressly covered hereunder are excluded regardless of which plan or rider is selected.
9. Vision or ear tests and the provision of visual or hearing aids.
10. Vocational, recreational, speech or music therapy.
11. Treatment while confined primarily to receive custodial care, educational or rehabilitative care, or nursing services.
12. Charges, injuries and/or illnesses resulting or arising from or occurring during the commission or continuing perpetration of a violation of law by the insured, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
13. Treatment for, and injuries and/or illnesses resulting or arising from, substance abuse or drug addiction.
14. Injury and/or illness resulting or arising from being under the influence of alcohol or drugs; and injury or illness resulting from operating any type of vehicle after consuming any alcohol or drugs.
15. Willful self-inflicted injury or illness.
16. Treatment required as a result of or arising from complications from a treatment or condition not covered under the certificate.
17. Any services or supplies performed or provided by a relative of the Insured or provided at no cost to Insured.
18. Treatment for mental and nervous disorders.
19. Organ or tissue transplants or related services.
20. Illness or injury where the trip to the host country is undertaken for treatment or advice for such illness or injury, except as expressly provided for in the certificate of insurance.
21. Treatment incurred as a result of or arising from exposure to nuclear radiation, and/or radioactive material(s).
22. Any infection of the urinary tract (or Illness arising therefrom), that occurs within ninety (90) days of the Effective Date of coverage and that requires Treatment of the Insured Person in a Hospital; provided that any such Illness will be deemed by the Company to be a Pre-existing Condition.
Acute Pre-Ex Coverage
A Pre-existing Condition which is any injury, illness, sickness, disease, or other physical, medical, mental or nervous disorder, condition or ailment that, with reasonable medical certainty, existed at the time of application or at any time during the three years prior to the effective date of the insurance, whether or not previously manifested, symptomatic or known, diagnosed, treated, or disclosed to the Company prior to the effective date, and including any and all subsequent, chronic or recurring complications or consequences related thereto or resulting or arising therefrom.
(U.S. citizens only) For those up to age 65 with a primary health plan, Outreach Group will pay the Usual, Reasonable and Customary charges of a sudden and unexpected recurrence of a Pre-existing Condition (defined on page 13) up to the plan maximum. For those without a primary health plan, Outreach Group will pay up to a $20,000 lifetime maximum. For those age 65 and older, with or without a primary health plan, Outreach Group will pay up to a $2,500 lifetime maximum. The primary health plan must have existed prior to the effective date and during coverage of the Outreach Group plan, and the Pre-existing Condition must be covered under the primary health plan.
(Non-U.S. citizens only) For those under age 65, Outreach Group will pay up to a $50,000 lifetime maximum for eligible medical expenses. For those age 65 and older, Outreach Group will pay up to $2,500 lifetime maximum.In addition, up to $25,000 will be paid to U.S. and non-U.S. citizens for the eligible costs and expenses of an Emergency Medical Evacuation arising or resulting from a sudden and unexpected recurrence of a Pre-existing Condition.
In addition, up to $25,000 will be paid to U.S. and non-U.S. citizens for the eligible costs and expenses of an Emergency Medical Evacuation arising or resulting from a sudden and unexpected recurrence of a Pre-existing Condition.
(Acute Onset of Pre-existing Condition means 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, is of short duration, is rapidly progressive, and requires urgent care.)
In the PPO Network - The plan pays 90% of eligible expenses up to $5,000, then 100% up to the Maximum Limit.
If your Outreach plan is purchased for a minimum of one month, coverage may be renewed (unless there is a break in coverage) for a total of up to two years. Renewals are available in whole month or daily increments and may be completed online or by using a paper application, however, renewals of less than one month are available only online. For each renewal of less than one month completed online, you will be charged an additional $5 processing fee. Each insured person must only satisfy one deductible and coinsurance within each 12 month coverage period. Please note: Renewal rates may differ from initial rates.
You will be required to pay a $50 cancellation fee and Only full month premiums will be considered for refunds (e.g., if you choose to cancel your coverage two months and two weeks prior to the date your coverage ends, IMG will only consider the two full months for a refund). If you have filed claims, your premium is non-refundable.
PRECERTIFICATION Each proposed hospital admission, in-patient or out-patient surgery, and other procedures as noted in the Certificate of Insurance must be Precertified for medical necessity, which means the insured person or their attending physician must communicate with an IMG representative at the number listed on the IMG identification card prior to admission to a hospital or performance of a surgery. In case of an emergency admission, the Precertification call must be made within 48 hours of the admission, or as soon as reasonably possible. If a hospital admission or a surgery is not Precertified, eligible claims and expenses will be reduced by 50%. It is important to note that Precertification is only a determination of medical necessity, not an assurance of coverage, verification of benefits or a guarantee of payment. All medical expenses eligible for reimbursement must be medically necessary and will be paid or reimbursed at usual, reasonable, and customary rates. Please refer to the Certificate Wording for full details of the Precertification requirements.
For Precertification, emergency evacuation, and return of mortal remains, please call: IMG in the U.S.: 1.800.628.4664 (toll free) or 1.317.655.4500. Call IMG outside the U.S.: 001.317.655.4500 (collect if necessary). This information will also be provided on your ID card.
Note: An insured person may begin the Precertification process through MyIMG or the Client Resources section of our website, www.imglobal.com. Simply look for the Precertification option. You will be asked to provide the required information, which can then be submitted electronically to IMG. Once we have confirmed receipt of your request, our utilization management and review team will review the information provided and respond to the insured person or the provider within two business days. Please note that this online service will only initiate the Precertification process, and it should not be used to Precertify emergency admissions, procedures, or evacuations.
CLAIM PAYMENT All benefits payable under Outreach Group Travel Medical Insurance are subject to the terms and conditions in the Certificate of Insurance. To make claim processing efficient, claims may be paid in two ways:
- Eligible expenses that have been paid by or on behalf of the insured person may be reimbursed by check directly to the insured person.
- Eligible expenses that have not yet been paid by the insured person may, at the option of IMG, be paid either to the insured person or directly to the provider.
Claim forms can be accessed at www.imglobal.com and mailed to International Medical Group, P.O. Box 88500, Indianapolis, IN 46208-0500 USA.
All IMG contact numbers, claim forms and the Certificate of Insurance are included in the fulfillment kit. IMG may also be contacted by fax: 1.317.655.4505 or email: firstname.lastname@example.org.