Only U.S. and Non-U.S. Citizens who are at least 14 days of age and are travelling outside of their Home Country, but not to the U.S. or U.S. Territories, are eligible for coverage under this plan. Individuals age 70 to 79 as of the Certificate Effective Date are subject to a $50,000 Overall Maximum. Individuals age 80 and over as of the Certificate Effective Date are subject to a $10,000 Overall Maximum.

SCHEDULE OF BENEFITS AND LIMITS

Except as specifically indicated otherwise, all benefits are subject to Deductible, Coinsurance, and are per Certificate Period.

BenefitLimit
Deductibles $0, $100, $250, $500, $1,000 or $2,500 per Certificate Period
Coinsurance – Claims incurred in U.S. or Canada For Home Country Coverage or during a Benefit Period, Underwriters will pay 90% of the next $10,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit. Coinsurance will be waived if expenses are incurred within the PPO and expenses are submitted to Underwriters for review and payment directly to the provider. There is no U.S. coverage unless Member is under Home Country Coverage or a Benefit Period.
Coinsurance – Claims incurred outside U.S. or Canada Underwriters will pay 100% of Eligible Expenses after the Deductible up to the Overall Maximum Limit
Hospital Room and Board Usual, Reasonable and Customary charges
Local Ambulance Usual, Reasonable and Customary charges, when covered Illness or Injury results in hospitalization as Inpatient
Intensive Care Unit Usual, Reasonable and Customary charges
Emergency Room Co-payment The Member shall be responsible for a $250 co-payment for each use of Emergency room for an Illness unless the Member is admitted to the Hospital. There will be no copayment for Emergency room treatment of an Injury.
Urgent Care Center For each visit, the Member shall be responsible for a $50 co-payment, after which Coinsurance will apply. Not subject to Deductible.
Outpatient Treatment Usual, Reasonable, and Customary charges
Physical Therapy and Chiropractic Care Usual, Reasonable and Customary charges
Hazardous Activities
(Available only under the optional Hazardous Activities Rider)
Overall Maximum Limit
Intercollegiate or Interscholastic Sports
(Available only under the optional Intercollegiate Sports Rider)
Usual, Reasonable and Customary charges up to $20,000
Mental Health Disorders Usual, Reasonable and Customary charges up to $5,000
Hospital Indemnity $100 per day of Inpatient hospitalization for a maximum amount of $500 (not subject to Deductible or Coinsurance).
All Other Eligible Medical Expenses Usual, Reasonable, and Customary charges
Acute Onset of Pre-existing Condition For members age 14 days through age 64 inclusive, $10,000; for members Age 65 and over, $2,500
Emergency Dental Treatment due to Accident $1,000
Emergency Dental (Acute Onset of Pain) $100 (not subject to Deductible or Coinsurance)
Emergency Medical Evacuation $250,000 Maximum Lifetime Limit (not subject to Deductible or Coinsurance)
Return of Minor Children $50,000 (not subject to Deductible or Coinsurance)
Repatriation of Remains $50,000 (not subject to Deductible or Coinsurance)
Political Evacuation $50,000 Maximum Lifetime Limit (not subject to Deductible or Coinsurance)
Lost or Stolen Passport/Travel Visa $100 (not subject to Deductible or Coinsurance).
Trip Interruption $5,000 (not subject to Deductible or Coinsurance).
Emergency Reunion $15,000, maximum of 15 days (not subject to Deductible or Coinsurance)
Natural Disaster Maximum $100 a day for 5 days (not subject to Deductible)
Lost Checked Luggage $250 limit per bag; $500 per Certificate Period (not subject to Deductible or Coinsurance).
Terrorism $50,000 Maximum Lifetime Limit, Eligible Medical Expenses only
Accidental Death and Dismemberment  
Members under age 18 Lifetime Maximum - $5,000
Death - Principal Sum
Loss of 2 Limbs - Principal Sum
Loss of 1 Limb - 50% of Principal Sum
Members age 18 to age 70 Lifetime Maximum - $50,000
Death – Principal Sum
Loss of 2 Limbs – Principal Sum
Loss of 1 Limb - 50% of Principal Sum
Members age 70 to age 74 inclusive Lifetime Maximum - $20,000.
Death – Principal Sum
Loss of 2 Limbs – Principal Sum
Loss of 1 Limb - 50% of Principal Sum
Members Age 75 and over: Lifetime Maximum - $10,000
Death – Principal Sum
Loss of 2 Limbs – Principal Sum
Loss of 1 Limb - 50% of Principal Sum
$250,000 Maximum Benefit any one family or Group
Overall Maximum Limit per Certificate Period (includes all benefits except Accidental Death and Dismemberment, Emergency Medical Evacuation and Common Carrier Accidental Death) Age 80 or older $10,000; Age 70 to 79: $50,000; All others: $25,000, $50,000, $100,000, $200,000, $500,000 or $1,000,000.

Charges for the following treatments and/or services and/or supplies and/or conditions are excluded from coverage hereunder:

  1. Routine pre-natal care, Pregnancy, child birth, and post natal care.
  2. 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 Complication of Pregnancy as herein defined, and all charges related to Pregnancy after the 26th week of Pregnancy.
  3. Charges incurred by or for any child under the age of 14 days.
  4. Diagnosis, testing, or treatment related to birth defects and congenital illnesses. Birth defects are deemed to include hereditary conditions.
  5. Charges for the diagnosis, testing, or treatment of Mental Health Disorders, as defined herein, except as provided under the Schedule of Benefits and Limits.
  6. Charges which are not Incurred, as herein defined, by a Member during his/her Certificate Period.
  7. Charges for treatment of any condition(s) when the purpose of departing the Home Country was to obtain treatment in the destination country/countries.
  8. Charges for any benefit hereunder which are not presented to Underwriters for payment within 60 days beginning on the last day of the Certificate Period.
  9. Diagnosis, testing, treatment, services or supplies that are not administered by or under the supervision of a Physician, and products that can be purchased without a doctor's prescription.
  10. Diagnosis, testing, or treatment, services or supplies which are not Medically Necessary as herein defined.
  11. Diagnosis, testing, or treatment, services or supplies provided at no cost to the Member.
  12. Charges which exceed Usual, Reasonable and Customary as herein defined.
  13. Telephone consultations or failure to keep a scheduled appointment.
  14. Surgeries, diagnosis, testing,treatments, services or supplies which are Investigational, Experimental or for Research purposes.
  15. All charges Incurred 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.
  16. Diagnosis, testing, or treatment of obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass Surgery.
  17. Modifications of the physical body intended to improve the psychological, mental or emotional well-being of the Member, including but not limited to sex-change Surgery.
  18. Surgeries, diagnosis, testing, treatments, services or supplies for cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is directly related to and follows a Surgery which was covered hereunder.
  19. Diagnosis, testing, or treatment for HIV+, AIDS or ARC, and all diseases caused by and/or related to HIV.
  20. Any drug, treatment or procedure that either promotes or prevents conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
  21. Any drug, treatment or procedure that either promotes, enhances or corrects impotency or sexual dysfunction.
  22. Willful and/or therapeutic termination of Pregnancy, except in connection with covered Complications of Pregnancy.
  23. Dental Treatment, 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.
  24. 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.
  25. Eye surgery, such as corrective refractive surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
  26. Diagnosis, testing, or treatment of the temporomandibular joint.
  27. Medical expenses for Injury or Illness resulting from:
    1. Professional Sports including practice;
    2. mountaineering at elevations of 4,500 meters or higher;
    3. aviation (except when traveling solely as a passenger in a commercial aircraft);
    4. base jumping, bungee jumping, parachuting, parasailing hang-gliding;
    5. sky surfing;
    6. off-road motorized vehicles including all-terrain vehicles, snowmobiles and motorized dirt bikes, jet skis, and tractors;
    7. heli-skiing, snow skiing, or snowboarding, except for recreational downhill and/or cross country snow skiing or snowboarding (no cover provided while skiing away from prepared and marked in-bound territories and/or against the advice of the local ski school or local authoritative body);
    8. water skiing, surfing, kayaking or white water rafting;
    9. racing by any animal, motorized vehicle, or BMX;
    10. spelunking or cave diving;
    11. sub aqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, or accompanied by a certified instructor at depths of less than 10 meters;
    12. avalanche training;
    13. Aussie rules football;
    14. safari or big game hunting, running with the bulls;
    15. bobsleigh, skeleton or luge;
    16. any type of boxing or martial arts;
    17. hot air ballooning as a pilot;
    18. jousting;
    19. modern pentathlon;
    20. powerlifting;
    21. quad biking outdoor endurance events;
    22. speed trials; speedway;
    23. wrestling;
    24. zip lining or canopying.
  28. Medical expenses for Injury or Illness resulting from participation in organized Intercollegiate or Interscholastic Athletics including intramural and Club sports except as provided in the Schedule of Benefits and Limits.
  29. Injury sustained while under the influence of or due wholly or partly to the effects of intoxicating liquor or drugs other than drugs taken in accordance with treatment prescribed and directed by a Physician except drugs prescribed by a Physician for the treatment of Substance Abuse.
  30. Costs resulting from self-inflicted Injury or Illness and/or suicide or attempted suicide whether sane or insane.
  31. Diagnosis, testing, or treatment of venereal disease, including all Sexually Transmitted Diseases and conditions.
  32. 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.
  33. Diagnosis, testing, or treatment of sleep apnea or other sleep disorders.
  34. Charges resulting from or occurring during the commission of a violation of law by the Member, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
  35. Diagnosis, testing, or treatment of Substance Abuse or addiction or conditions that may be attributed to Substance Abuse or addictions and direct consequences thereof.
  36. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.
  37. Psychometric, intelligence, competency, behavioral and educational testing.
  38. Any services, supplies, diagnosis, testing, or treatment performed or provided by a Relative of the Member or any family member of the Member or any person who ordinarily resides with the Member.
  39. Orthoptics and visual eye training.
  40. Diagnosis, testing, treatment or supplies for the feet: 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.
  41. Diagnostic testing or procedures, services, supplies, and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Physician.
  42. Pre-existing Conditions – Charges resulting directly or indirectly from any Pre-existing Condition, as herein defined, are excluded from this insurance, except charges resulting directly from an Acute Onset of Pre-existing Condition, as herein defined, are covered for all Members subject to the limits set forth in the Schedule of Benefits and Limits.
  43. Exercise programs, whether or not prescribed or recommended by a Physician.
  44. Diagnosis, testing, or treatment required as a result of complications or consequences of a treatment or condition not covered hereunder.
  45. Charges for 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.
  46. Diagnosis, testing, or treatment incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
  47. Organ or Tissue Transplants or related services.
  48. Diagnosis, testing, or treatment for acne, other acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of sebaceous glands, hypertrophic and atrophic conditions of skin, nevus.
  49. Diagnosis, testing, or treatment of all forms of cancer / neoplasm.
  50. All expenses of any cryo preservation and implantation or re-implantation of living cells.
  51. All Emergency Medical Evacuation or Repatriation of Remains costs not approved or arranged in advance by Underwriters.
  52. Medical conditions while on duty as a member of a police or military force unit.
  53. Claims payable under any government system, including the Australian Medicare system, are excluded from coverage.
  54. The Accidental Death & Dismemberment benefit shall be excluded with respect to Accidents occurring while the Member is participating in any of the following:
    1. War or act of war, whether declared or undeclared.
    2. The member's participation in a riot, insurrection or violent disorder.
    3. The member's service in the armed forces of any country.
    4. Suicide or attempted suicide or self-inflicted Injury, while sane or insane.
    5. The voluntary use of any chemical compound, poison or drug, unless used according to the directions of a Physician.
    6. Committing or attempting to commit a felony.
    7. Sickness, Mental Health Disorder, or Pregnancy.
    8. As the result of Intoxication as defined by the laws of the jurisdiction in which the accident occurred of the Member, whether directly or indirectly,
    9. Myocardial infarction or cerebrovascular accident (CVA / Stroke).
    10. Infection, except infection through a wound caused solely by an accident.
    11. Injury while riding, boarding, or alighting from an aircraft if the Member was operating the aircraft, learning to operate the aircraft, serving as a member of the aircraft crew, or if the aircraft was being used for any purpose other than passenger transportation.
    12. Medical or surgical treatment for any of the above.
    13. Any of the following activities:
      1. Amateur Athletics, Contact Sports, Intercollegiate or Interscholastic Athletics, intramural, and club sports or athletic activities and Professional Sports including practice. Non-contact and nonorganized/ non-sanctioned amateur sports or athletic activities engaged in by the Member solely for leisure, recreational, entertainment or fitness purposes are not excluded unless they are excluded by (2) through (24) of this provision; and
      2. mountaineering at elevations of 4,500 meters or higher;
      3. aviation (except when traveling solely as a passenger in a commercial aircraft);
      4. base jumping, bungee jumping, parachuting, parasailing hang-gliding;
      5. sky surfing;
      6. Off-road motorized vehicles including all-terrain vehicles, snowmobiles and motorized dirt bikes, jet skis, and tractors;
      7. Heli-skiing, snow skiing, or snowboarding, except for recreational downhill and/or cross country snow skiing or snowboarding (no cover provided while skiing away from prepared and marked inbound territories and/or against the advice of the local ski school or local authoritative body);
      8. Water skiing, surfing, kayaking or white water rafting;
      9. racing by any animal, motorized vehicle, or BMX;
      10. Spelunking or cave diving;
      11. sub aqua pursuits involving underwater breathing apparatus unless PADI/NAUI certified, or accompanied by a certified instructor at depths of less than 10 meters;
      12. avalanche training;
      13. Aussie rules football;
      14. Safari or big game hunting, running with the bulls;
      15. bobsleigh, skeleton or luge;
      16. Any type of boxing or martial arts,
      17. hot air ballooning as a pilot;
      18. jousting;
      19. modern pentathlon;
      20. powerlifting;
      21. quad biking outdoor endurance events,
      22. speed trials; speedway;
      23. wrestling;
      24. Zip lining or canopying.
  55. Services, diagnosis, testing, supplies, or treatment that are not included as Eligible Expenses as described herein.

Pre-existing Condition: Any (1) condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the 18 months immediately preceding the Certificate Effective Date; (2) condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 18 months immediately preceding the Certificate Effective Date; (3) injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 18 months immediately preceding the Certificate Effective Date. For the purposes of the Complications of Pregnancy coverage offered hereunder, Pregnancy will not be included within the definition of a Preexisting Condition.

Acute Onset of Pre-existing Condition For members age 14 days through age 64 inclusive, $10,000; for members Age 65 and over, $2,500

Acute Onset of Pre-existing Condition: The term "Acute Onset of a Pre-Existing Condition(s)" shall mean a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning 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 effective date of the policy. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to the Effective Date of coverage.

Members may review a listing of Hospitals, Physicians and other medical service providers included in the PPO Network for the area where the Member will be receiving treatment by accessing the Internet website for HCC Medical Insurance Services, LLC at:

Non Renewable.

Premiums may be refunded after the Certificate Effective Date subject to the following provisions:

  1. a $25 cancellation fee will apply; and
  2. only the unused portion of the plan cost will be refunded; and
  3. only Members who have no claims are eligible for premium refund.

CLAIM PROCEDURES

Notice of Claim, Claimant's Statement and Authorization, and Proof of Claim must be mailed to:
HCC Medical Insurance Services, LLC
P.O. Box 2005
Farmington Hills, MI 48333-2005

Proof of Claim –

When Underwriters receive notice of claim, they will provide the Member 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; and
  2. Original itemized bills from Physicians, Hospitals and other medical providers; and
  3. Original receipts for any expenses which have already been paid by or on behalf of the Member.

The Member shall have 60 days beginning on the last day of the Certificate Period to submit Proof of Claim to Underwriters. Subsequent to receipt of Proof of Claim, Underwriters may, at their 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.

Appealing a Claim –

Time Limit – In the event Underwriters deny all or part of a claim under this insurance, the Member shall have 90 days from the date the notice of denial was mailed to the Member's last known address to file a written appeal with Underwriters. 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.

Appeal Procedure – Within 60 days of Underwriters' receipt of the appeal, Underwriters' will review the claim. A written response will be forwarded to the Member. Within 60 days of receipt of Underwriters' response to the appeal, the Member may initiate a second appeal. Within 60 days of Underwriters' 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 the Member.