MEMBER ELIGIBILITY

U.S. Citizens and Non-U.S. Citizens who are at least 14 days of age and are traveling outside of their home countries but not to the U.S. or U.S. territories. U.S. Citizens and residents are not eligible for coverage within the U.S, except as provided under home country coverage or an eligible benefit period. Individuals age 80 and over as of the certificate effective date are subject to a $10,000 overall maximum limit

CERTIFICATE EFFECTIVE & TERMINATION DATES

CERTIFICATE EFFECTIVE DATE

Insurance hereunder is effective on the later of:

a. The moment we receive an application and correct premium if the application and payment is made online or by fax;

b. 12:01am U.S. Eastern Time on the date we receive an application and correct premium if the application and payment is made by mail;

c. The moment you depart from your home country; or

d. 12:01am U.S. Eastern Time on the date requested on the application.

CERTIFICATE TERMINATION DATE

Insurance hereunder terminates on the earlier of:

a. 11:59pm U.S. Eastern Time on the last day of the period for which premium has been paid;

b. 11:59pm U.S. Eastern Time on the date requested on the application; or

c. The moment of arrival upon your return to your home country (unless you have started a benefit period or are eligible for home country coverage).

BENEFIT PERIOD & HOME COUNTRY COVERAGE

BENEFIT PERIOD

While the certificate is in effect, the benefit period does not apply. Upon termination of the certificate, in accordance with this provision, we will pay eligible medical expenses for up to 90 days beginning on the first day of diagnosis or treatment of a covered injury or illness while you are outside your home country. The benefit period applies only to eligible medical expenses related to the injury or illness that began while the certificate was in effect.

In the event you begin a benefit period while the certificate is in effect, and the certificate terminates because you return to your home country, we will pay eligible medical expenses which are incurred in your home country during the benefit period. Home country coverage applies only to eligible medical expenses related to the injury or illness that began while the certificate was in effect.

INCIDENTAL HOME COUNTRY COVERAGE

U.S. home country: For every three-month period during which you are covered, eligible medical expenses incurred in the U.S. are covered up to a maximum of 15 days.

Non-U.S. home country: For every three-month period during which you are covered, eligible medical expenses incurred in your home country are covered up to a maximum of 30 days.

Any benefit accrued under a single three-month period does not accumulate to another period. Failure to continue your international trip or your return to your home country for the sole purpose

of obtaining treatment for an illness or injury that began while traveling shall void any home country coverage provided under the terms of this agreement.

Except for a benefit period, coverage provided under this Master Policy is for a maximum duration of 364 days.

Notwithstanding the foregoing, coverage under all plans shall terminate on the date we, at our sole option, elect to cancel all members of the same sex, age, class or geographic location, provided we give no less than 30 days advance written notice by mail to your last known address.

Accidental Death means a sudden, unintentional and unexpected occurrence caused solely by external, visible means resulting in physical injury to you and your subsequent death. Death must occur within 30 days of the sudden, unintentional and unexpected occurrence and not be contributed to by illness or disease.

Accidental Dismemberment means a sudden, unintentional and unexpected occurrence caused solely by external, visible means and resulting in complete severance from the body of one or more limbs or eyes and not contributed to by illness or disease. For purposes of the Accidental Death and Dismemberment benefit, the term “limb” shall mean: the arm when the severance is at or above (toward the elbow) the wrist, or the leg when the severance is at or above (toward the knee) the ankle. Loss of eye(s) shall mean: complete, permanent, irrevocable loss of sight.

Beneficiary means the individual named in your application to be the recipient of any Accidental Death benefit. If you do not designate a beneficiary on the application, the beneficiary is automatically as follows:

Members age 18 or older: 1. Spouse (if any), 2. Children (if any) equally, 3. Your estate.

Members under age 18: 1. Custodial Parent(s) (if any), 2. Siblings (if any) equally, 3. Your estate

Accidental Dismemberment means a sudden, unintentional and unexpected occurrence caused solely by external, visible means and resulting in complete severance from the body of one or more limbs or eyes and not contributed to by illness or disease. For purposes of the Accidental Death and Dismemberment benefit, the term “limb” shall mean: the arm when the severance is at or above (toward the elbow) the wrist, or the leg when the severance is at or above (toward the knee) the ankle. Loss of eye(s) shall mean: complete, permanent, irrevocable loss of sight.

Acute Onset of Pain (Emergency Dental) means a sudden and unexpected occurrence of pain which occurs spontaneously and without advance warning, either in the form of physician or dentist recommendation or symptoms, including pain, which would have caused a prudent person to seek medical or dental attention prior to the onset of pain. Treatment must be obtained within 24 hours of the sudden and unexpected occurrence of pain.

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. The Acute Onset of a Pre-existing Condition(s) must occur after the certificate effective date. 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 certificate effective date.

Beneficiary means the individual named in your application to be the recipient of any Accidental Death benefit. If you do not designate a beneficiary on the application, the beneficiary is automatically as follows:

Members age 18 or older: 1. Spouse (if any), 2. Children (if any) equally, 3. Your estate.

Members under age 18: 1. Custodial Parent(s) (if any), 2. Siblings (if any) equally, 3. Your estate.

Certificate means the document issued to you that provides evidence of benefits payable under the Master Policy and that will confirm the plan type, period of cover, home country, certificate number, special terms and/or conditions, deductible, chosen benefit list, and geographical area of cover.

Certificate Period means the period of time beginning on the date and time of the certificate effective date and ending on the date and time of the certificate termination date. The maximum certificate period is 364 days.

Coinsurance means your payment of eligible expenses at the percentage specified in the Schedule of Benefits and Limits.

Complications of Pregnancy means illnesses whose diagnoses are distinct from pregnancy, but are adversely affected by pregnancy or caused by pregnancy and not associated with a normal pregnancy. This includes: ectopic pregnancy, spontaneous abortion, hyperemesis gravidarum, pre-eclampsia, eclampsia, missed abortion and conditions of comparable severity. Complications of Pregnancy does not include: false labor, edema, prolonged labor, prescribed rest during the period of pregnancy, morning sickness and conditions of comparable severity associated with management of a difficult pregnancy, and not constituting a medically distinct condition.

Custodial Care means that type of care or service, wherever furnished and by whatever name called,

that is designed primarily to assist you in performing the activities of daily living. Custodial care also includes non-acute care for the comatose, semi-comatose, paralyzed or mentally incompetent patients.

Cyber means the use or operations, as a means for inflicting harm, of any computer, computer software program, malicious code, computer virus or process or any other electronic system.

Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and Limits that you must pay per certificate period before eligible expenses are paid.

Displaced means required to depart a destination due to an evacuation ordered by prevailing authorities.

Durable Medical Equipment means a standard basic hospital bed and/or a standard basic wheelchair.

Educational or Rehabilitative Care means care for restoration (by education or training) of one’s ability to function in a normal or near normal manner following an illness or injury. This type of care includes, but is not limited to, vocational or occupational therapy and speech therapy.

Emergency means a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing your life or limb in danger if medical attention is not provided within 24 hours.

Extended Care Facility means an institution, or a distinct part of an institution, which is licensed as a hospital, extended care facility or rehabilitation facility by the state in which it operates; and is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a physician and the direct supervision of a registered nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a physician; and provides each patient with active treatment of an illness or injury. Extended care facility does not include a facility primarily for rest, the aged, substance abuse treatment, custodial care, nursing care or for care of mental health disorders or the mentally incompetent.

Home Country means the country where you principally reside and receive regular mail. U.S. Citizens are not eligible for coverage within the U.S., except as provided under home country coverage, regardless of the location of your principal residence.

Home Health Care Agency means a public or private agency or one of its subdivisions, which operates pursuant to law and is regularly engaged in providing home nursing care under the supervision of a registered nurse, and maintains a daily record on each patient, and provides each patient with a planned program of observation and treatment by a physician.

Home Nursing Care means services provided by a home health care agency and supervised by a registered nurse, which are directed toward the personal care of a patient, provided always that such care is provided in lieu of medically necessary inpatient care in a hospital.

Hospital means an institution which operates as a hospital pursuant to law, and is licensed by the state or country in which it operates; and operates primarily for the reception, care and treatment of sick or injured persons as inpatients; and provides 24-hour nursing service by registered nurses on duty or call; and has a staff of one or more physicians available at all times; and provides organized facilities and equipment for diagnosis and treatment of acute medical conditions on its premises; and is not primarily a rehabilitation facility, long-term care facility, extended care facility, nursing, rest, custodial care or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment.

Illness means a sickness, disorder, illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. For purposes of this insurance, illness includes Complications of Pregnancy during the first 26 weeks of pregnancy. Illness does not include learning disabilities, attitudinal disorders or disciplinary problems.

Injury means an unexpected and unforeseen harm to the body caused by an accident that requires medical treatment.

Inpatient means a patient who occupies a hospital bed for more than 24 hours for medical treatment and whose admission was recommended by a physician, or a patient held for observation in a hospital for at least 12 hours.

Intensive Care Unit means a cardiac care unit or other unit or area of a hospital that meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.

Investigational, Experimental or for Research Purposes means procedures, services or supplies that are by nature or composition, or are used or applied, in a way which deviates from generally accepted standards of current medical practice.

Medically Necessary means a service or supply which is necessary and appropriate for the diagnosis or treatment of an illness or injury based on generally accepted current medical practice as determined by us. A service or supply will not be considered medically necessary if is provided only as a convenience to you or the provider, and/or is not appropriate for your diagnosis or symptoms, and/or exceeds in scope, duration or intensity that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment of an illness or injury.

Member means an individual who is covered under this insurance.

Mental Health Disorder means a mental or emotional disease or disorder which generally denotes a disease of the brain with predominant behavioral symptoms; or a disease of the mind or personality, evidenced by abnormal behavior; or a disorder of conduct evidenced by socially deviant behavior. Mental health disorders include: psychosis, depression, schizophrenia, bipolar affective disorder, and those psychiatric illnesses listed in the current edition of the diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association.

Natural Disaster means an event of natural cause, including wildfire, earthquake, windborne dust or sand, volcanic eruption, tsunami, snow, rain or wind, that results in widespread and severe damage.

Natural disaster does not include the direct or indirect effect of rain, wind or water associated with named storms meeting the definition of hurricane or typhoon, except in instances where:

1. The path of the named storm deviates by a distance of greater than 200 miles within a 72-hour period from the path forecast by a nationally recognized meteorological service

2. Or less than 72 hours advance notice of a potential landfall for a named storm exists.

Outpatient means a member who receives medically necessary treatment by a physician for injury or illness that does not require overnight stay in a hospital.

Physician means a Doctor of Medicine (MD), Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DDM), Doctor of Podiatry (DPM), Doctor of Osteopathy (DO), Doctor of Chiropractic, a licensed Physical Therapist or Physiotherapist, and a Doctor of Psychiatry (Psy.D) and a Doctor of Psychology (Ph.D.). Physician also includes a Certified Nurse Practitioner (CNP), Certified Registered Nurse Anesthetist (CRNA), Nurse Midwife or a Physician Assistant (PA) under the direction of a medical doctor. A physician must be currently licensed by the jurisdiction in which the services are provided, and the services must be within the scope of that license and covered under this Master Policy.

Relative means biological or step parent; biological or step child; current spouse; biological or stepsiblings; or parent, children, or sibling in law.

Routine Physical Exam means and examination of the physical body by a physician for preventative or informative purposes only, and not for the diagnosis or treatment of any condition.

Sexually Transmitted Diseases means diseases including but not limited to syphilis, gonorrhea, chlamydiosis, trichomoniasis, genital herpes, and Human Papillomavirus (HPV).

Substance Abuse means alcohol, drug or chemical abuse, overuse or dependency.

Surgery or Surgical Procedure means an invasive diagnostic procedure or the treatment of illness or injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.

Urgent Care Center means a U.S. medical facility separate from a hospital emergency department where ambulatory patients can be treated on a walk-in basis without an appointment and receive immediate, non-routine urgent care for an injury or illness presented on an episodic basis.

Usual, Reasonable and Customary means the lesser of the following:

1. One and a half times (150%) of the charges payable under the United States Medicare program, for claims incurred outside the PPO network within the U.S., or

2. Most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. What is defined as usual, reasonable and customary charges will be determined by us. In determining whether a charge is usual, reasonable and customary, we may consider one or more of the following factors: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the severity or nature of the illness or injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; such other factors we, in the reasonable exercise of discretion, determine are appropriate.

You/Your means each insured person named in the certificate.

We/Us/Our means Tokio Marine HCC - Medical Insurance Services Group.

SCHEDULE OF BENEFITS AND LIMITS

Plan Details

 

Overall Maximum Limit

Age 80 or older $10,000.

Age 65 to 79: $50,000 or $100,000.

All others: $50,000,$100,000, or $150,000

Maximum per Injury / Illness

Age 80 or older $10,000.
Age 65 to 79: $50,000 or $100,000.
All others: $50,000, $100,000, or $150,000.

Deductibles

$0, $250, $500, or $1,000 per certificate period

Coinsurance – Claims incurred outside U.S.

We will pay 100% of eligible expenses after the deductible up to the overall maximum limit

Coinsurance – Claims incurred in U.S.

 

In-Network Payment

Within the PPO: We will pay 100% of eligible expenses, after the deductible, to the overall maximum limit.

Out-of-Network Payment

Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount.

Eligible expenses are subject to deductible, coinsurance, overall maximum limit,

and are per certificate period unless specifically indicated otherwise

Benefit

Limit

Hospital Room and Board

Average semi-private room rate, including nursing services

Intensive Care Unit

Up to the overall maximum limit

Local Ambulance

Usual, reasonable and customary charges, when covered illness or injury results in hospitalization as inpatient.

Emergency Room Co-payment

Claims incurred outside the U.S.

No co-payment

Claims incurred in U.S.

You shall be responsible for a $250 co-payment for each use of emergency room for an illness unless you are admitted to the hospital. There will be no co-payment for emergency room treatment of an injury

Urgent Care Center Co-payment

Claims incurred outside the U.S.

No co-payment

Claims incurred in U.S.

For each visit, you shall be responsible for a $50 co-payment, after which coinsurance will apply.

– Co-payment is waived for members with a $0 deductible.

– not subject to deductible

Outpatient Physical Therapy and Chiropractic Care

Usual, reasonable and customary charges. Must be ordered in advance by a physician

Emergency Dental Treatment due to Accident

Up to $2,000

Emergency Dental (Acute Onset of Pain)

Up to $250 - not subject to deductible or coinsurance

Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions)

Age 80 or older: $5,000

Ages 60 to 79: $20,000

Under age 60: Up to the overall maximum limit

Up to $25,000 lifetime maximum for Emergency Medical Evacuation

Terrorism

Up to $50,000 lifetime maximum, eligible medical expenses only

Optional Hazardous Activities Rider

Up to the overall maximum limit

Optional Intercollegiate or Interscholastic Sports Rider

Up to $50,000

All Other Eligible Medical Expenses

Up to the overall maximum limit

Emergency Travel Benefits

Limit

Emergency Medical Evacuation

Up to $500,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Repatriation of Remains

Up to $50,000 - not subject to deductible, coinsurance, or overall maximum limit

Emergency Reunion

Up to $20,000, subject to a maximum of 15 days - not subject to deductible or coinsurance

Return of Minor Children

Up to $50,000 - not subject to deductible or coinsurance

Political Evacuation

Up to $50,000 lifetime maximum - not subject to deductible or coinsurance

Trip Interruption

Up to $5,000 - not subject to deductible or coinsurance

Accidental Death & Dismemberment

 

Ages 18 through 69

Lifetime Maximum - $50,000

Death - $50,000

Loss of 2 Limbs - $50,000

Loss of 1 Limb - $25,000

Under age 18

Lifetime Maximum - $5,000

Death - $5,000

Loss of 2 Limbs - $5,000

Loss of 1 Limb - $2,500

Ages 70 through 74

Lifetime Maximum - $20,000

Death - $20,000

Loss of 2 Limbs - $20,000

Loss of 1 Limb - $10,000

Ages 75 and older

Lifetime Maximum - $10,000

Death - $10,000

Loss of 2 Limbs - $10,000

Loss of 1 Limb - $5,000

 

$250,000 maximum benefit any one family or group.

- not subject to deductible, coinsurance, or overall maximum limit

Optional Enhanced Accidental Death & Dismemberment Rider (only available to members under age 70)

Lifetime Maximum - $100,000

Death - $100,000

Loss of 2 Limbs - $100,000

Loss of 1 Limb - $50,000

- not subject to deductible, coinsurance, or overall maximum limit

Lost Checked Luggage

Up to $500 - not subject to deductible or coinsurance

Lost or Stolen Passport/Travel Visa

Up to $100 - not subject to deductible or coinsurance

Natural Disaster - Replacement Accommodations

Up to $100 a day for 5 days - not subject to deductible or coinsurance

Hospital Indemnity

$100 per day for 5 days for inpatient hospitalization - not subject to deductible or coinsurance

General Exclusions

Excluded Conditions, Treatments (includes Diagnoses, Tests, and Examinations), Services, Supplies, Acts, Omissions, and/or Events:
1.    Pre-existing Conditions, except charges resulting directly from an Acute Onset of Pre-existing Condition, as herein defined, subject to the limits set forth in the Schedule of Benefits and Limits.
2.    Birth defects and congenital illnesses. Birth defects are deemed to include hereditary conditions.
3.    Mental health disorders.
4.    Pregnancy except as covered under Complications of Pregnancy, as herein defined, termination of pregnancy except in connection with covered Complications of Pregnancy, all charges related to pregnancy after the 26th week of pregnancy, routine prenatal care, child birth, postnatal care, and charges incurred by a child under the age of 14 days.
5.    Impotency or sexual dysfunction.
6.    All sexually transmitted diseases and conditions.
7.    HIV, AIDS, or ARC, and all diseases caused by and/or related to HIV.
8.    All forms of cancer / neoplasm.
9.    Substance abuse or addiction or conditions that may be attributed to substance abuse or addictions and direct consequences thereof.
10.    Acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, hypertrophic and atrophic conditions of skin, nevus.
11.    Sleep apnea or other sleep disorders.
12.    Obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass surgery.
13.    Self-inflicted injury or illness and/or suicide or attempted suicide whether sane or insane.
14.    Injury sustained that is due wholly or partially to the effects of intoxication or drugs other than drugs taken in accordance with treatment prescribed by a physician and except drugs prescribed for the treatment of substance abuse.
15.    Injury sustained while operating any motorized vehicle, aircraft or watercraft whether registered or not while under the influence of alcohol as defined under the law of the jurisdiction where the injury occurs or with a
.08 Blood Alcohol Content (BAC), whichever is lower.
16.    Routine medical examinations, including but not limited to vaccinations, immunizations, annual check-ups, the issue of medical certificates and attestations, and examinations as to the suitability of employment or travel.
17.    Dental treatment and treatment of the temporomandibular joint, except for emergency dental treatment necessary to replace sound natural teeth lost or damaged in an accident covered hereunder or for the emergency relief of acute onset of pain.
18.    Promotion or prevention of conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
19.    Organ or tissue transplants or related services.
20.    Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
21.    Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations.
22.    Orthoptics and visual eye training.
23.    Orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or toenails.
24.    Hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed.
25.    Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinesiotherapy.
26.    Psychometric, intelligence, competency, behavioral and educational testing.
27.    Cosmetic or aesthetic reasons, except for reconstructive surgery when such surgery is directly related to and follows a surgery which was covered hereunder.
28.    Modifications of the physical body intended to improve the psychological, mental or emotional well-being, including but not limited to sex-change surgery.
29.    Exercise programs, whether or not prescribed or recommended by a physician.
30.    Incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
31.    Cryo preservation and implantation or re-implantation of living cells.
32.    Genetic or predictive testing.
33.    Investigational, experimental or for research purposes.
34.    While confined primarily to receive custodial care, educational or rehabilitative care, or any medical treatment in any establishment for the care of the aged, except rehabilitative care received upon direct transfer from an acute care hospital.
35.    Not medically necessary.
36.    Not administered by or under the supervision of a physician, and products that can be purchased without a doctor's prescription.
37.    Provided by a relative, family member or any person who ordinarily resides with you.
38.    Provided at no cost to you.
39.    Failure to keep a scheduled appointment.
40.    Payable under any government system, including the Australian Medicare system.
41.    Payable under Worker’s Compensation or Employer’s Liability Laws, or by any coverage provided or required by law.
42.    Charges exceeding usual, reasonable and customary.
43.    Charges resulting from or occurring during the commission of a violation of law, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
44.    Any illness or injury incurred 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 your effective date, any of the following were issued:
a.    The United States Centers for Disease Control & Prevention had issued a Warning/Alert Level 3 or higher for a location or destination, including common carriers; or
b.    The United States Centers for Disease Control & Prevention had issued a Global or Worldwide Warning/Alert Level 3 or higher.
This exclusion is applicable when 1) any of the above were in effect within 6 months immediately prior to your effective date or 2) within 10 days following the date the alert/warning is issued you have failed to depart the country or location. This exclusion does not apply to charges resulting from COVID-19/SARS- CoV-2.
45.    War, military action or while on duty as a member of a police or military force unit.
46.    Travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Repatriation of Remains, Emergency Reunion, Natural Disaster, Return of Minor Children, Political Evacuation, and Trip Interruption sections of this insurance.
47.    Incurred outside your certificate period.
48.    Submitted to us for payment more than 60 days after the last day of the certificate period.
49.    When departure from the home country is to obtain treatment in the destination country/countries.
50.    Complications or consequences of a treatment or condition not covered hereunder.
51.    Not included as Eligible Expenses as described herein.

PRE-EXISTING MEDICAL CONDITIONS

Beneift

Limit

Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions)

 

Age 80 or older: $5,000

Ages 60 to 79: $20,000

Under age 60: Up to the overall maximum limit

Up to $25,000 lifetime maximum for Emergency Medical Evacuation

Acute Onset of Pre-existing Condition
YOU ARE COVERED:
1.    Charges for a sudden and unexpected outbreak or recurrence of a pre-existing condition(s) which:
a.    Occurs    spontaneously    and    without    advance    warning    either    in    the    form    of    physician recommendations or symptoms; and
b.    Is of short duration; and
c.    Is rapidly progressive; and
d.    Requires urgent care.

YOU ARE NOT COVERED unless you fulfill the following condition:
1.    Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence.

YOU ARE NOT COVERED IF:
1.    The Acute Onset of a Pre-existing Condition(s) occurs before the certificate effective date; or
2.    The pre-existing condition is
a.    a chronic or congenital condition; or
b.    a complication or consequence of a chronic or congenital condition; or
c.    a condition that gradually becomes worse over time; or
3.    The charges are for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the certificate effective date; or
4.    Expenses arise directly or indirectly from anything in the General Exclusions.

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. The Acute Onset of a Pre-existing Condition(s) must occur after the certificate effective date. 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 a complication or consequence of a chronic or congenital condition, or a condition 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 certificate effective date.

U.S. Preferred Provider Organization (PPO)
This insurance policy offers the option of a PPO network for medical treatment received in the United States. If you choose to seek treatment from a PPO provider, billed charges for eligible expenses may be reduced and we will remit payment directly to the provider. Additionally, we will apply the in-network coinsurance applicable to the expenses.

You may review a listing of hospitals, physicians and other medical service providers included in the PPO Network for the area where you will be receiving treatment by accessing the Internet website for WorldTrips: www.worldtrips.com. For assistance locating a provider, contact us at 1-800-605-2282.

Click here for PPO Network

Non Renewable.

CANCELLATION

We hope you are happy with the cover this policy provides. However, if after reading it, this insurance does not meet with your requirements, please notify us of your wish to cancel and we will refund your premium.
Premiums will be refunded in full if a cancellation request is received prior to the certificate effective date. Premiums may be refunded after the certificate effective date subject to the following provisions:

  1. $25 cancellation fee will apply for administrative costs incurred by us; and
  2. Only the unused portion of the plan cost will be refunded; and
  3. You cannot have filed any claims to be eligible for a premium refund.

Claims

This insurance policy has in it a Claims Procedure which tells you what steps you must take to file a claim, and explains our obligations to you. Beginning on the last day of your certificate period, you shall have 60 days to provide us proof of claim.

Appeals and Complaints
This insurance policy has in it an Appeal and Complaints Procedure which tells you what steps you can take if you wish to make an appeal or complaint.

Claim Procedures
You must submit a claim for any expenses to be paid by us. This includes treatment or services for which the medical provider will bill us directly. No payments will be made by us without you first submitting a claim.
Notice of claim, Claimant’s Statement and Authorization, and proof of claim must be mailed to:

WorldTrips
P.O. Box 2005
Farmington Hills, MI 48333-2005 USA

Proof of Claim
When we receive notice of a claim, we will provide you with forms for filing proof of claim. The following is considered to be proof of claim:

  1. A completed and signed Claimant’s Statement and Authorization form, together with any/all required attachments;
  2. Original itemized bills from physicians, hospitals and other medical providers; and
  3. Original receipts for any expenses which have already been paid by you or on your behalf.

Beginning on the last day of your certificate period, you shall have 60 days to provide us proof of claim (unless medical services were rendered after the certificate termination date, in which case you shall have 60 days from the date the claim is incurred). Subsequent to receipt of proof of claim, we may, at our sole discretion, request and require additional information, including but not limited to medical records, necessary to confirm the validity of any claim prior to payment thereof.

Claims Cooperation
You shall provide assistance and cooperate with us or our representatives in obtaining any other records we or they feel necessary to evaluate the incident or claim. Following notification of a claim, you shall provide, when asked, all authorizations necessary to obtain your medical records. If you do not cooperate with us and/or our investigation of the claim, we shall not be liable to pay any claim.

Access to Additional Materials
You shall provide us, or our designated representatives, all information, documentation, medical information that we or they may reasonably require during the term of this policy, or until all claims have been resolved, whichever is later.

Other Insurance
We shall not pay any claim if there is other insurance which would, or would but for the existence of this insurance, pay such claim. This insurance will apply with respect to expenses in excess of the amount paid or payable under such other insurance. We shall not pay any claim in respect to care, treatment, services or supplies furnished by any program or agency funded by any government.

Appealing a Claim
In the event we deny all or part of a claim under this insurance, you may file a written appeal with us. The written appeal must include sufficient information to identify the claim under appeal and must specify the reason(s) for the appeal with supporting documentation, if applicable.


Please provide your written appeal online, by email, or by postal mail at the following:
Online:    http://service.worldtrips.com/
Email:    appeals@worldtrips.com
Postal Mail:    WorldTrips Appeals
P.O. Box 2058
Farmington Hills, MI 48333, USA

When we receive the appeal, we will review the claim and a written response will be sent to you. After you receive our response to the appeal, you may initiate a second appeal. With our receipt of the second appeal, medical and/or claims personnel who were not involved in the original claim determination or the initial appeal will review the claim. A final determination will be made and a letter will be sent to you.

Please note that appealing a claim is not a requirement to following the complaints procedure detailed below.