MEMBER ELIGIBILITY

  1. Only individuals traveling outside of their home country who are at least 14 days of age are eligible for coverage under this plan. U.S. citizens must be traveling outside of the continental U.S., Alaska, Hawaii, Puerto Rico, and the U.S. Virgin Islands in order to be eligible. For individuals coming to the U.S. who are over age 65, coverage must be effective within 30 days of arrival.
  2. Individuals ages 80 and above must select Plan A. Individuals ages 70 to 79 may select Plan A or Plan B. Individuals age 69 and under may select any plan.

CERTIFICATE EFFECTIVE & TERMINATION DATES

CERTIFICATE EFFECTIVE DATE

Insurance hereunder is effective on the later of:

  1. The moment we receive an application and correct premium if the application and payment is made online or by fax;
  2. 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;
  3. The moment you depart from your home country; or
  4. 12:01am U.S. Eastern Time on the date requested on the application

CERTIFICATE TERMINATION DATE

Insurance hereunder terminates on the earlier of:

  1. 11:59pm U.S. Eastern Time on the last day of the period for which premium has been paid
  2. 11:59pm U.S. Eastern Time on the date requested on the application; or
  3. 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).

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.

Accident means a sudden, unintentional and unexpected occurrence caused by external, visible means and resulting in physical injury to you. The cause or one of the causes of such accident is external to your own body and occurs beyond your control.

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.

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.

Common Carrier means an airplane, bus, train or watercraft operating for commercial purposes and carrying fare-paying passengers on regularly scheduled and published routes. 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.

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 illnessor 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 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.

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.

Observation means the use of a bed and periodic monitoring and/or short term treatment by a hospital’s nursing or other staff. These services are considered reasonable and necessary to evaluate a patient’s condition to determine the need for possible inpatient admission. Observation care provides a method of evaluation and treatment as an alternative to inpatient hospitalization. The services may be considered eligible for coverage only when provided under a physician’s order or under the order of another person who is authorized by state statute and the hospital’s by laws to admit patients and order outpatient testing. The observation services must be patient-specific and not part of a standard operating procedure or facility protocol for a given diagnosis or service.

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), 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).

Specialist Physician means a doctor of medicine (MD) who has completed the training for and has become certified in a specialty or sub-specialty of the medical arts. Specialist Physician does not include a Doctor of Chiropractic (DC), a Doctor of Psychiatry (PsyD) or Doctor of Psychology (PhD). 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.

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

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

DEDUCTIBLE

 

Plan A

Plan B

Plan C

Plan D

Ages 14 days -69 years

$0, $50, or $100

 

 

 

Age 70 and over

$100 or $200

 

 

 

Ages 80 and above

$100 or $200

 

 

 

OVERALL POLICY MAXIMUM

Ages 14 days - 69 years

$50,000

$75,000

$100,000

$130,000

Ages 70-79

$50,000

$75,000

 

 

Ages 80 and above

$10,000

 

 

 

INPATIENT TREATMENT

 

Plan A

Plan B

Plan C

Plan D

Hospital Room &Board, including miscellaneous

unless specified

$1,450 per day,

30 days max

$1,725 per day,

30 days max

$2,000 per day,

30 days max

$2,585 per day,

30 days max

Intensive Care Unit, including miscellaneous

unless specified

$2,200 per day,

8 days max

$2,600 per day,

8 days max

$3,000 per day,

8 days max

$3,800 per day,

8 days max

Surgery

$3,600 per session

$4,800 per session

$6,000 per session

$7,800 per session

Consultant physician

$450

$475

$500

$650

Private duty nurse

$550

$550

$550

$700

Physician visits

$60 per visit,

30 visits max

$75 per visit,

30 visits max

$90 per visit,

30 visits max

$115 per visit,

30 visits max

OUTPATIENT TREATMENT

 

 

 

 

Surgery

$3,300 per session

$4,400 per session

$5,500 per session

$7,150 per session

OutpatientSurgical

Facility

$1,100

$1,150

$1,200

$1,500

Pre-admission Testing

$1,100

$1,100

$1,100

$1,450

Diagnostic X-ray and Labs

$500, plus $400 for one CAT Scan,

MRI or PET

$550, plus $450

for one CAT Scan,

MRI or PET

$600, plus $500

for one CAT Scan,

MRI or PET

$750, plus $650

for one CAT Scan,

MRI or PET

Emergency Room (all expenses incurred therein)

$375

$485

$600

$785

Observation Room

Services (all expenses incurred therein)

$355

$465

$575

$750

Outpatient Prescription Drugs

$150

$200

$250

$300

Office Visits, including Urgent Care

$70 per visit,

10 visits max

$85 per visit,

10 visits max

$100 per visit,

10 visits max

$130 per visit,

10 visits max

MISCELLANEOUS INPATIENT & OUTPATIENT TREATMENT

 

 

 

 

Anesthesiologist

$825

$1,110

$1,375

$1,775

Assistant Surgeon

$825

$1,110

$1,375

$1,775

Local Ambulance

$500

$500

$500

$500

Dental Accident

$550

$550

$550

$550

Physical Therapy

$40 per visit, 1 visit per day, maximum 12 visits

$40 per visit, 1 visit per day, maximum 12 visits

$40 per visit, 1 visit per day, maximum 12 visits

$40 per visit, 1 visit per day, maximum 12 visits

Mental & Nervous

Disorder & Substance Abuse

Same as any

Illness

Same as any

Illness

Same as any

Illness

Same as any

Illness

Durable Medical

Equipment

$1,100

$1,200

$1,300

$1,700

Acute Onset of

Pre-existing Condition

(only available to

members under age 70)

$50,000 Lifetime

Maximum for

Eligible Medical

Expenses, $25,000 Lifetime Maximum for Emergency Medical Evacuation

$75,000 Lifetime

Maximum for

Eligible Medical

Expenses,$25,000 Lifetime Maximum for Emergency Medical Evacuation

$100,000 Lifetime

Maximum for

Eligible Medical

Expenses, ,$25,000 Lifetime Maximum for Emergency Medical Evacuation

$100,000 Lifetime

Maximum for

Eligible Medical

Expenses, ,$25,000 Lifetime Maximum for Emergency Medical Evacuation

OTHER BENEFITS

Not subject to deductible or overall policy maximum

 

 

 

 

EmergencyMedical

Evacuation

$50,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing

Condition. Available only to members under age 70

$50,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing

Condition. Available only to members under age 70

$50,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing

Condition. Available only to members under age 70

$50,000 Lifetime Maximum, except as provided under Acute Onset of Pre-existing

Condition. Available only to members under age 70

Repatriation of Remains

$25,000

$25,000

$25,000

$25,000

Local Burial & Cremation

$5,000

$5,000

$5,000

$5,000

Common Carrier

Accidental Death &

Dismemberment

$25,000 Lifetime Maximum Principal Sum

Death or Loss of Two Limbs – Principal Sum

Loss of One Limb – One-half the Principal Sum

Subject to a maximum of $125,000 any one family or group

$25,000 Lifetime Maximum Principal Sum

Death or Loss of Two Limbs – Principal Sum

Loss of One Limb – One-half the Principal Sum

Subject to a maximum of $125,000 any one family or group

$25,000 Lifetime Maximum Principal Sum

Death or Loss of Two Limbs – Principal Sum

Loss of One Limb – One-half the Principal Sum

Subject to a maximum of $125,000 any one family or group

$25,000 Lifetime Maximum Principal Sum

Death or Loss of Two Limbs – Principal Sum

Loss of One Limb – One-half the Principal Sum

Subject to a maximum of $125,000 any one family or group

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

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.

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

 

PLAN A: $50,000

PLAN B: $75,000

PLAN C: $100,000

PLAN C: $130,000

Acute Onset of Pre-existing Condition (only for age below 70)

$50,000 Lifetime

Maximum for

Eligible Medical

Expenses, $25,000 Lifetime Maximum for Emergency Medical Evacuation

$75,000 Lifetime

Maximum for

Eligible Medical

Expenses, $25,000 Lifetime Maximum for Emergency Medical Evacuation

$100,000 Lifetime

Maximum for

Eligible Medical

Expenses, $25,000 Lifetime Maximum for Emergency Medical Evacuation

$100,000 Lifetime

Maximum for

Eligible Medical

Expenses, $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 chronic or congenital condition or 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 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.

EXCLUSIONS

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.

Renew

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.

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

  • Cuba
  • Iran
  • North Korea
  • Sudan