SCHEDULE OF BENEFITS AND LIMITS

All benefits, except Emergency Medical Evacuation, Repatriation of Remains, and Common Carrier Accidental Death and Dismemberment, are subject to deductible and are per injury or illness, up to the overall policy maximum, unless stated otherwise

 

PRE-EXISTING MEDICAL CONDITIONS

This policy does not cover pre-existing conditions, except charges resulting directly from an Acute Onset of Pre-existing Condition subject to the limits set forth in the Schedule of Benefits and Limits.

Pre-existing Condition means 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 2 years 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 2 years immediately preceding the certificate effective date; or

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 2 years 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 pre-existing condition.

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.

MEDICAL & REPATRIATION EXPENSES

Subject to the limits set forth in the Schedule of Benefits and Limits, and subject to the conditions andrestrictions contained in this provision, we will pay the following expenses incurred while this insurance is in effect.

INPATIENT BENEFITS

YOU ARE COVERED:

1. Hospital room and board expenses including:

a. Daily room and board and nursing services not to exceed the amount and duration specified in the Schedule of Benefits and Limits; and

b. Services, supplies, and other hospital miscellaneous which are routinely provided by the hospital to persons for use while inpatient; and

c. Diagnostic testing using radiology, ultrasonic or laboratory services (psychometric, intelligence, competency, behavioral and educational testing are not included); and

d. Care in an extended care facility following direct transfer from an acute care hospital, provided such care is recommended by the attending physician for convalescence related to the illness or injury for which you were hospitalized as inpatient. Extended care facility benefits accrue toward the limits for

Hospital Room and Board.

2. Intensive Care Unit:

a. Daily room and board and nursing services in intensive care unit not to exceed the amount and duration specified in the Schedule of Benefits and Limits; and

b. Services, supplies, and other hospital miscellaneous which are routinely provided by the hospital to persons for use while inpatient; and

c. Diagnostic testing using radiology, ultrasonic or laboratory services.

3. Inpatient Surgery: Professional services provided by a physician, specialist physician, and/or surgeon fordiagnosis, treatment, and surgery of a covered condition. All covered expenses relating to an inpatient surgery, including physician consultations prior to and after surgery, will be paid under the inpatient surgery benefit.

4. Inpatient professional fees for a consultant physician when the consultant physician has been requested and approved by the attending physician.

5. Routine pre-admission testing consisting of major diagnostic procedures, including but not limited to CAT scans, NMR’s, and blood chemistries, will be payable under the “Hospital Miscellaneous” benefit

6. Private duty nursing care while hospitalized as inpatient, when ordered by a licensed physician, and if medically necessary, but not to include general nursing care provided by the hospital.

7. Physician visits while you are hospitalized as inpatient, limited to one visit per day and when hospitalization is not related to surgery.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

OUTPATIENT BENEFITS

Charges for physician, virtual physician, and urgent care center office visits, including injections administered during visit, for visits not covered under the Outpatient Surgery Benefit.

YOU ARE COVERED:

1. Outpatient Surgery: Professional services provided by a physician, specialist physician, and/or surgeon for diagnosis, treatment, and surgery of a covered condition. All covered expenses relating to an outpatient surgery will be paid under the Outpatient Surgery benefit unless otherwise covered by the Outpatient Surgical Facility benefit.

2. Outpatient Surgical Facility: Miscellaneous charges, including operating room, laboratory tests and x-ray exams, professional fees, anesthesia, drugs or medicines (but not for take home drugs), therapeutic services and supplies, when related to an outpatient surgery covered hereunder.

3. Routine pre-admission testing including but not limited to complete blood count, urinalysis, and chest x-ray completed within seven days prior to the date of hospital admission.

4. Diagnostic testing using radiology, ultrasonic or laboratory services other than such services that are related to a covered outpatient surgery.

5. Emergency room expenses, including charges for use of the emergency room itself and any supplies or other charges incurred during use of the emergency room for a covered injury, even if hospital confinement is not required, or for a covered illness which results in hospitalization as inpatient.

6. Observation room services, when an observation stay (a period not to exceed 48 hours) meets the following conditions:

    a. The patient is clinically unstable for discharge; and

    b. Clinical monitoring, and/or laboratory, radiologic, or other testing is necessary in order to assess the patient’s need for hospitalization; or

    c. The treatment plan is not established or, based upon the patient’s condition, is anticipated to be completed within a period not to exceed 48 hours; or

   d. Changes in status or condition are anticipated and immediate medical intervention may be required.

7. Changes in status or condition are anticipated and immediate medical intervention may be required.

8. For drugs which require prescription by a physician for treatment of a covered injury or illness, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of 60 days per prescription.

9. Charges for physician and urgent care center office visits, including injections administered during visit, for visits not covered under the Outpatient Surgery Benefit.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

INPATIENT OR OUTPATIENT BENEFITS

YOU ARE COVERED:

1. Professional services provided by an anesthesiologist and/or assistant surgeon up to 25% each of   the Usual, reasonable and customary charge of the primary surgeon. Standby availability will not be deemed to be a professional service and therefore will not be covered hereunder.

2. Emergency Local Ambulance transport necessarily incurred in connection with injury or illness resulting in inpatient hospitalization.

3. Emergency Dental Treatment necessary to restore or replace sound natural teeth lost or damaged in an accident which was covered under this insurance.

4. Medically necessary rental of durable medical equipment (consisting of a standard basic hospital bed and or a standard basic wheelchair) up to the purchase prices.

5. Physical therapy if prescribed by a physician who is not affiliated with the physical therapy practice, necessarily incurred to continue recovery from a covered Injury or Illness.

6. Treatment for mental and nervous disorders, including substance abuse, as specified in the Schedule of Benefits. Physician visits are limited to one per day.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

EMERGENCY MEDICAL EVACUATION

YOU ARE COVERED:

1. Emergency air transportation to a suitable airport nearest to the hospital where you will receive treatment; and

2. Emergency ground transportation necessarily preceding emergency air transportation; and from the destination airport to the hospital where you will receive treatment.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The evacuation is recommended by the attending physician who certifies that it is medically necessary and that transportation by any other method would result in the loss of your life or limb; and

2. The evacuation is agreed upon by you or your relative; and

3. Travel arrangements, excluding Emergency Local Ambulance, are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. The illness or injury giving rise to the expense is not covered under this insurance; or

2. Medically necessary treatment, services and supplies can provided locally; or

3. If transportation by any other method would not result in the loss of your life or limb; or

4. The condition giving rise to the Emergency Medical Evacuation did not occur spontaneously and without advance warning, either in the form of physician recommendation or symptoms which would have caused a prudent person to seek medical attention prior to the onset of the emergency; or

5. Expenses are directly or indirectly from anything in the General Exclusions.

We will provide Emergency Medical Evacuation only to the nearest hospital that is qualified to provide the medically necessary treatment, services and supplies to prevent your loss of life or limb.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

Notwithstanding the foregoing, and if you are visiting the U.S., we will pay for expenses to return you to your home country if the attending physician and our medical consultant agree that transfer to your home country is more appropriate than transfer to the nearest qualified hospital.

REPATRIATION OF REMAINS

YOU ARE COVERED:

1. Air or ground transportation of bodily remains or ashes to the airport or ground transportation

    terminal nearest your principal residence; and

2. Reasonable costs of preparation of the remains necessary for transportation

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The illness or injury giving rise to the expense are covered under this insurance; and

2. Travel arrangements are approved in advance and coordinated by us

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

We are held harmless and shall not be held liable for loss of or any damage or other impairment to bodily remains incurred during the repatriation process or otherwise.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

LOCAL BURIAL OR CREMATION

YOU ARE COVERED:

1. For you to be buried or cremated in the country of death in lieu of Repatriation of Remains up to the specified benefit maximum.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The illness or injury giving rise to the expense is covered under this insurance; and

2. Travel arrangements are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. The death occurs in your home country; or

2. The Emergency Medical Evacuation or Repatriation of Remains benefit is used; or

3. Expenses arise directly or indirectly from anything in the General Exclusions

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

COMMON CARRIER ACCIDENTAL DEATH BENEFIT

YOU ARE COVERED:

1. The amount indicated in the Schedule of Benefits to the beneficiary.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The accident giving rise to the accidental death must occur while you are a fare paying passenger on a regularly scheduled trip on board a commercial airline or cruise line;

2. Death must occur with 30 days of the sudden, unintentional and unexpected occurrence and not be contributed to by illness or disease; and

3. The maximum liability under this Common Carrier Accidental Death Benefit for a group or family is limited to $125,000.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

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 or Common Carrier 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

SPORTS AND ACTIVITIES

YOU ARE COVERED:

1. You are covered for taking part in amateur/non-professional sports and activities, unless it is excluded  below. Coverage is for recreational purposes incidental to a trip.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You must ensure the activity is adequately supervised and that appropriate safety equipment (such as protective headwear, life jackets etc.) are worn at all times.

YOU ARE NOT COVERED IF:

1. The activity is organized athletics involving regular or scheduled practice and/or games; or

2. The activity is performed in a professional capacity or for any wage, reward, or profit; or

3. Expenses arise directly or indirectly from anything in the General Exclusions; or

4. Any of the excluded items listed below:

• All-Terrain Vehicles

• American Football

• Aussie Rules Football

• Aviation (except when traveling solely as a

passenger in a commercial aircraft)

• Base Jumping

• Big Game Hunting

• Bobsleigh

• Boxing

• Cave Diving

• Hang-Gliding

• Heli-Skiing

• Hot Air Ballooning as a Pilot

• Ice Hockey

• Jousting

• Kite-Surfing

• Luge

• Martial Arts

• Modern Pentathlon

• Motorized Dirt Bikes

• Mountaineering at elevations of 4,500

meters or higher

• Outdoor Endurance Events

• Parachuting

• Paragliding

• Parasailing

• Powerlifting

• Quad Biking

• Racing by any Animal, Motorized Vehicle, or

BMX, and Speed Trials and Speedway

• Rugby

• Running with the Bulls

• Skeleton

• Sky Surfing

• Snow  Skiing  and  Snowboarding,  except

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)

• Snow Mobiles

• Spelunking

• Sub  Aqua  Pursuits  involving  underwater

breathing apparatus unless accompanied by a

certified instructor at depths less than 10 meters,

or PADI/NAUI certified

• Tractors

• Whitewater Rafting

• Wrestling

 TERRORISM

This policy does not cover injuries or illnesses resulting from an Act of Terrorism.

YOU ARE NOT COVERED FOR:

1. Loss, damage, cost or expense directly or indirectly caused by, resulting from or in connection with any of the following regardless of any other cause or event contributing concurrently or in any other sequence to the loss, damage, cost or expense:

a. War, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power;

b. The use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon; however, this exclusion shall not apply where you are exposed to nuclear radioactive and/or radioactive material for the purpose of medical treatment;

c. Any Act of Terrorism;

d. Coverage for loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to (a), (b) or (c) above; or

e. Expenses arise directly or indirectly from anything in the General Exclusions.

For the purpose of this insurance, an “Act of Terrorism” means an act, including but not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.

If we allege that by reason of this exclusion, any loss, damage, cost or expense is not covered by this insurance, the burden of proving the contrary shall be upon you.

In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.

 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.

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. are deemed to include hereditary conditions Pregnancy, termination of pregnancy, routine prenatal care, childbirth, postnatal care, and charges incurred by a child under the age of 14 days.
3. Impotency or sexual dysfunction.
4. All sexually transmitted diseases and conditions.
5. HIV, AIDS, or ARC, and all diseases caused by and/or related to HIV.
6. All forms of cancer / neoplasm.
7. Acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, hypertrophic and atrophic conditions of skin, nevus.
8. Sleep apnea or other sleep disorders.
9. Obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass surgery.
10. Self-inflicted injury or illness and/or suicide or attempted suicide whether sane or insane.
11. 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.
12. 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.
13. 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.
14. 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.
15. Promotion or prevention of conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
16. Organ or tissue transplants or related services.
17. Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
18. 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.
19. Orthoptics and visual eye training.
20. 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.
21. Hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed.
22. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinesiotherapy.
23. Psychometric, intelligence, competency, behavioral and educational testing.
24. Cosmetic or aesthetic reasons, except for reconstructive surgery when such surgery is directly related to and follows a surgery which was covered hereunder.
25. Modifications of the physical body intended to improve the psychological, mental or emotional well- being, including but not limited to sex-change surgery.
26. Exercise programs, whether or not prescribed or recommended by a physician.
27. Incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
28. Cryo preservation and implantation or re-implantation of living cells.
29. Genetic or predictive testing.
30. Investigational, experimental or for research purposes.
31. While confined primarily to receive custodial care, educational or rehabilitative care, or any medical treatment in any establishment for the care of the aged.
32. Not medically necessary.
33. Not administered by or under the supervision of a physician, and products that can be purchased without a doctor's prescription.
34. Provided by a relative, family member or any person who ordinarily resides with you.
35. Provided by home nursing care.
36. Provided by a chiropractor.
37. Provided at no cost to you.
38. Failure to keep a scheduled appointment.
39. Payable under any government system, including the Australian Medicare system.
40. Payable under Worker’s Compensation or Employer’s Liability Laws, or by any coverage provided or required by law.
41. Charges exceeding usual, reasonable and customary.
42. 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.
43. 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:
    1. 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
    2. 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.

44.War, military action or while on duty as a member of a police or military force unit.

45.Travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Emergency Quarantine Indemnity, and Repatriation of Remains sections of this insurance.

46.Diagnosis, treatment, services, or supplies provided by Home Nursing Care.

47.Incurred within your home country.

48.Incurred outside your certificate period.

49.Submitted to us for payment more than 60 days after the last day of the certificate period.

50.When departure from the home country is to obtain treatment in the destination country/countries.

51.Complications or consequences of a treatment or condition not covered hereunder.

52.Not included as Eligible Expenses as described herein.

This policy does not cover pre-existing conditions, except charges resulting directly from an Acute Onset of Pre-existing Condition subject to the limits set forth in the Schedule of Benefits and Limits.

 

Pre-existing Condition means 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 2 years 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 2 years immediately preceding the certificate effective date; or

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 2 years immediately preceding the certificate effective date.

 

YOU ARE COVERED:

1. Charges for a sudden and unexpected outbreak or recurrence of a pre-existing condition(s) which:
   1. Occurs when you are under age 70; and
   2. Occurs spontaneously   and   without   advance   warning   either   in   the   form   of   physician

recommendations or symptoms; and

1. Is of short duration; and
2. Is rapidly progressive; and
3. 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 chronic or congenital condition; or
• a complication or consequence of a chronic or congenital condition; or
• a condition that gradually becomes worse over time; or

1. The charges are for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the certificate effective date; or
2. Expenses arise directly or indirectly from anything in the General Exclusions.

You may extend policy online before expiration date of policy. You may extend minimum of 5 days. Insurance company charge $5 extension fee for each renewal. Total coverage duration cannot be more than 364 days including extension.

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 y our 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:

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

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:

Tokio Marine HCC - MIS Group
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.

ARBITRATION

Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration by the American Arbitration Association in accordance with its Consumer Arbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Where any dispute is by this provision referred to arbitration, the making of an award shall be a condition precedent to any right of action against us.

APPEAL AND COMPLAINTS PROCEDURE

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 or by postal mail at the following:

http://service.hccmis.com/ or

Tokio Marine HCC - MIS Group
P.O. Box 2005
Farmington Hills, MI 48333-2005
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.

COMPLAINTS PROCEDURE

We are dedicated to providing a high-quality service and want to ensure that it is maintained at all times. If you feel that we or another party connected with this policy have not offered a first class service please contact us and we will do our best to resolve the problem.

Please provide your written complaint online or by postal mail at the following:

http://service.hccmis.com/ or

Tokio Marine HCC - MIS Group
P.O. Box 2005
Farmington Hills, MI 48333-2005
USA

You will be contacted within 3 (three) business days of receiving your complaint to inform you of what action is being taken. We will try to resolve the problem and give you an answer within four weeks. If it will take longer than four weeks we will tell you when you can expect an answer. If you have not been given an answer within 8 (eight) weeks we will tell you how you can take your complaint to the Financial Ombudsman Service for review. This complaints procedure does not affect any legal right you have to take action. Once you have received your final response from us, and if you are still not satisfied you can contact the Financial Ombudsman Service:

Financial Ombudsman Service

Exchange Tower, Harbour Exchange Square, London, E14 9SR

Phone: +44 (0) 20 7964 0500

Email: complaint.info@financial-ombudsman.org.uk

If you have purchased your policy online or by other electronic means within the European Union (EU) you may also make your complaint via the EU’s online dispute resolution (ODR) platform. The website for the ODR platform is: http://ec.europa.eu/odr

APPEALS AND COMPLAINTS

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

ARBITRATION AND CLASS ACTION WAIVER

Excluding claims for injunctive or other equitable relief, any dispute or controversy between a Member and any of the MIS Group, Underwriters or their affiliates arising out of or relating to this Master Policy, including without limitation, any and all disputes, claims (whether in tort, contract, statutory or otherwise) or disagreements concerning the existence, breach, interpretation, application or termination of this Master Policy, shall be resolved by final and binding arbitration pursuant to the Federal Arbitration Act and in accordance with the JAMS Inc. Comprehensive Arbitration Rules & Procedures then in effect. Such claims shall be arbitrated on an individual basis only and the parties waive any right or authority for any claims to be resolved in a class, consolidated, representative, collective or private attorney general action or arbitration. Instructions regarding how to commence an arbitration are available on the JAMS website, located at https://www.jamsadr.com. The arbitration shall take place in Houston, Texas or at the option of the party seeking relief, by telephone, online, or via written submissions alone, and be administered by JAMS. The arbitral tribunal (“Tribunal”) shall be composed of one arbitrator, who shall be independent and impartial. If the parties fail to agree on the arbitrator within twenty (20) calendar days after the initiation of an arbitration hereunder, JAMS shall appoint the arbitrator. The arbitration shall be conducted in the English language. The decision of the arbitrator will be final and binding on the parties. Judgment on any award(s) rendered by the arbitrator may be entered in any court having jurisdiction thereof. The arbitrator shall have the authority to determine arbitrability of any disputes arising out of or relating to this Master Policy. Nothing in this Section shall prevent either party from seeking immediate injunctive relief from any court of competent jurisdiction, and any such request shall not be deemed incompatible with the agreement to arbitrate or a waiver of the right to arbitrate. The parties undertake to keep confidential all awards in their arbitration, together with all confidential information, all materials in the proceedings created for the purpose of the arbitration and all other documents produced by the other party in the proceedings and not otherwise in the public domain, save and to the extent that disclosure may be required of a party by legal duty, to protect or pursue a legal right or to enforce or challenge an award in legal proceedings before a court or other judicial authority. The arbitrator shall award all fees and expenses, including reasonable attorney’s fees, to the prevailing party. This agreement to arbitrate does not apply to claims Members may have for medical malpractice against their medical providers.

Members may choose to opt out of the agreement to arbitrate by mailing a written opt-out notice (“Notice”) to Tokio Marine HCC – MIS Group. The Notice must be postmarked no later than sixty (60) days after the last day of your certificate period. The Notice must be mailed to: HCC Insurance Holdings, 13403 NW Freeway, Houston, Texas 77040, to the attention of General Counsel. This procedure is the only mechanism by which you can opt out of the agreement to arbitrate. Opting out of the agreement to arbitrate has no effect on any other parts of this Master Policy, or any previous or future arbitration agreements that you have entered into with Tokio Marine HCC-MIS Group

No coverage available for these countries when selected on application as home country, citizenship country or destination country.

• Cuba
• Iran
• North Korea
• Sudan