Detail

           

                                                                        ELIGIBILITY

 

 

If an Insured Person is not eligible, this Certificate is void ab initio and all Premium paid will be refunded. In order to be eligible and qualified for coverage under this insurance, a person must meet all of the following requirements: (1) not be a citizen of or have a permanent residence in the United States

(2) not be a citizen of the Destination Country

(3) be at least fourteen (14) days old and less than seventy-nine (79) years of age

(4) complete and sign an Application as the Insured Person (or be listed thereon by proxy as an applicant and proposed Insured Person), and/or as the Insured Person’s Spouse and/or Child

(5) pay the required Premium on or before the Effective Date of Coverage

(6) receive written acceptance of his/her Application, renewal or extension from the Company

(7) on the Effective Date and on subsequent renewal dates, must have legally departed the Country of Residence and legally entered the Destination Country

(8) not be Hospitalized, Disabled or HIV + on the Initial Effective Date

 

 

                                    TERMINATION OF COVERAGE FOR INSURED PERSONS

 

Coverage and benefits for the Insured Person under this insurance will terminate effective at 12:01 AM EST on the earliest of the following dates: (a) the date the Master Policy is terminated pursuant to the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF MASTER POLICY provision

(b) the next day following the end of the coverage period for which Premium has been fully and timely paid

(c) the termination date as shown on the Declaration for this Certificate

(d) the date the Insured Person first fails to meet or no longer meets the eligibility requirements for this insurance as set forth in the Master Policy and outlined in this Certificate

(e) the date the Insured Person returns to his/her Country of Residence unless covered as an INCIDENTAL TRIP

(f) the next day following twenty-four (24) months from the Initial Effective Date

(g) the date the Company, at its sole option, elects to cancel from this plan all Insured Persons of the same sex, age, class or geographic location as the Insured Person, provided the Company gives no less than thirty (30) days advance written notice by mail to the Insured Person's last known residence or mailing address of its intent to exercise such option

(h) the date the Insured Person enters active military service

(i) the cancellation date specified by the Company pursuant to the CONDITIONS AND GENERAL PROVISIONS, CANCELLATION BY INSURED PERSON provision

(j) the cancellation date specified by the Insured Person pursuant to the CONDITIONS AND GENERAL PROVISIONS, RENEWAL; AMENDMENTS provision

(k) the date specified by the Company in any notice of cancellation, forfeiture or rescission issued pursuant to or as a result of the circumstances described in the MISREPRESENTATION, FRAUDULENT CLAIMS and RIGHT OF RECOVERY subparagraphs of the CONDITIONS AND GENERAL PROVISIONS, or as otherwise permitted by the Terms of this insurance.

 

Coverage for the Insured Person shall remain in full force and effect unless terminated pursuant to this provision, except as otherwise provided in the Master Policy, the Declaration, or this Certificate.

 

 

DEFINITIONS

 

Certain words and phrases used in this Certificate are defined below. Other words and phrases may be defined elsewhere in this Certificate, including where they are first used.

 

Accident: An Unexpected occurrence directly caused by external, visible means and resulting in physical Injury to the Insured Person.

 

Adventure Sports: Activities undertaken for the purposes of recreation, an unusual experience or excitement. These activities are typically undertaken outdoors and involve a medium degree of risk.

 

AIDS: Acquired Immune Deficiency Syndrome, as that term is defined by the United States Centers for Disease Control.

 

Amateur Athletics: An amateur or other non-professional sporting, recreational, or athletic activity that is organized, sponsored and/or sanctioned, and/or involves regular or scheduled practices, games and/or competitions. Amateur Athletics does not include athletic activities that are non-organized, non-contact, non-collision, and engaged in by the Insured Person solely for recreational, entertainment or fitness purposes.

 

Ancillary Services: All Hospital services for a patient other than room and board and professional services. Laboratory tests and Radiology are examples of Ancillary Services.

 

Application: The fully answered and signed individual or Family Application/enrollment form submitted by or on behalf of the Insured Person for acceptance into, renewal of coverage under this insurance plan, which Application shall be incorporated in and become part of the Master Policy and this Certificate and the insurance contract. Any insurance agent/broker or other person or entity assigned to, soliciting, or assisting with the Application is the agent and representative of the applicant/Insured Person and is not and shall not be deemed or considered as an agent or representative for or on behalf of the Company or the Plan Administrator.

ARC: AIDS-related complex, as that term is defined by the United States Centers for Disease Control.

 

Assured: The Global Medical Services Group Insurance Trust, c/o Mutual Wealth Management Group, Carmel, IN.

 

Certificate Period: The period beginning on the Effective Date of Coverage of this Certificate, including any extension purchases, and ending on the earliest of the following dates:

(a) the termination date specified in the Declaration

(b) the termination date as determined in accordance with the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF COVERAGE FOR INSURED PERSONS provision.

 

Certificate; Certificate of Insurance: This document as issued to the Insured Person, that describes and provides an outline and evidence of eligible coverages and benefits payable to or for the benefit of the Insured Person under the insurance contract, which includes the Master Policy, Application, Declaration and any Riders.

 

Charges: Any cost, fee or tax incurred for Eligible Medical Expenses incurred in the Treatment of an Injury or Illness.

 

Child; Children: An Insured Person who is at least fourteen (14) days old but less than nineteen (19) years of age.

 

Class VI: A section of a river, stream or other waterway or watercourse where the current moves with enough speed or force to meet, but not to exceed, the qualifications of Class VI as determined by the International Scale of River Difficulty or as commonly published by a local authority or government agency.

 

Coinsurance: The payment by or obligations of the Insured Person for payment of ELIGIBLE MEDICAL EXPENSES at the percentage specified in the BENEFIT SUMMARY contained herein and not including any applicable Deductible.

 

Collision Sports: A sport in which the participants purposely hit or collide with each other or inanimate objects, including the ground, with great force and limited to the following: American football, boxing, ice hockey, lacrosse, full contact martial arts, rodeo, rugby and wrestling.

 

Common Carrier: A company or organization that holds itself out to the public as engaging in the business of transporting persons from place to place by air, rail, bus and/or water for compensation, offering its scheduled services to the public generally, and is licensed by a recognized and approved government authority to transport fare-paying passengers. The term Common Carrier does not include taxi, motorcar, motorcycle, or limousine services, or transportation by animal or human means (for example, by horse, camel, elephant or rickshaw).

 

Company: The Company, as referred to in the Master Policy and this Certificate, is Sirius International Insurance Corporation (publ), headquartered in Stockholm, Sweden. This insurance and its risks are underwritten by the Company as the insurer and carrier, and the Company is solely obligated and liable for the coverage and benefits provided by this insurance.

 

Congenital Disorder: Any abnormality, deformity, disease, Illness, Injury or medical condition present at birth, whether diagnosed or not.

Country of Residence: The Country of Residence is the country in which the Insured Person maintains his/her current primary residence or usual place of abode and any country to which the Insured Person pays income taxes based upon employment in that country. In the event there is more than one Country of Residence under the above-listed criteria, the Country of Residence is the country meeting the above-listed criteria and listed by the Insured Person as his or her Country of Residence on the Application.

 

Custodial Care: Those types of Treatment, care or services, wherever furnished and by whatever name called, that are designed primarily to assist an individual in activities of daily life.

 

Declaration: The Declaration of Insurance issued by the Plan Administrator for and on behalf of the Company to the Insured Person contemporaneously with this Certificate (and/or upon renewal hereof) evidencing the Insured Person’s insurance coverage under the Master Policy as evidenced by this Certificate.

 

Deductible: The dollar amount, as selected on the Application and specified in the Declaration, that the Insured Person must pay of ELIGIBLE MEDICAL EXPENSES per Period of Coverage prior to receiving benefits or coverage under this insurance, and not including any applicable Coinsurance.

 

Dental Provider; Dentist: A person duly licensed to practice dentistry in the state or country in which the dental service is rendered.

 

Dental Treatment: Treatment or supplies relating to the care, maintenance or repair of teeth, gums or bones supporting the teeth, including dentures and preparation for dentures.

 

Destination Country: All the geographical areas that the Insured Person is traveling to or within other than the primary place of residence declared on the application as the Country of Residence.

 

Durable Medical Equipment (DME): Exclusively the following items: a standard basic hospital bed, standard basic wheelchair or the initial orthopedic prosthetic.

 

Educational or Rehabilitative Care: Care for restoration (by education or training) of a person’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 job training, counseling, vocational or occupational therapy, and speech therapy.

Effective Date; Effective Date of Coverage: The later of (a) the date of coverage for the Insured Person as indicated on the Declaration or (b) the date that the Insured Person departs his/her Country of Residence.

 

Emergency: A medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person's life or limb in danger if medical attention is not provided within twenty-four (24) hours, based upon a reasonable medical certainty. Immediate medical intervention and attention is required as a result of a severe, life-threatening or potentially disabling condition.

 

Emergency Medical Evacuation: Emergency transportation from the Hospital or medical Facility where the Insured Person is located to a non-local Hospital or medical Facility following the recommendation by the attending Physician who certifies, to a reasonable medical certainty, that the Insured Person has experienced:

(a) a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person's life or limb in danger if medical attention is not provided within twenty-four (24) hours; and

(b) where Medically Necessary Treatment cannot be provided locally, either in the Facility of the attending Physician or another local Facility.

 

EST: United States Eastern Standard Time.

 

Experimental: Any Treatment that includes completely new, untested drugs, procedures, or services, or the use of which is for a purpose other than the use for which they have previously been approved; new drug procedure or service combinations; and/or alternative therapies which are not generally accepted standards of current medical practice.

 

Extended Care Facility: An institution, or a distinct part of an institution, which is licensed as a Hospital, Extended Care Facility or rehabilitation Facility by the state or country in which it operates; and is regularly engaged in providing twenty-four (24) hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a Physician; and provides each patient with active Treatment of an Illness or Injury. Extended Care Facility does not include a Facility primarily for rest, the aged, Substance Abuse, Custodial Care, nursing care, or for care of Mental or Nervous Disorders or the mentally incompetent.

 

Extreme Sports: Recreational activities involving a high degree of risk. These activities often involve speed, height, a high level of physical exertion, and/or highly specialized gear and often carry the potential risk of serious or permanent physical Injury and even death.

 

Facility: Licensed health care entity such as a Hospital, clinic, rehabilitation, and/or Extended Care Facility.

 

Family: An Insured Person and his/her Spouse who is covered as an Insured Person under this insurance plan and his/her natural Child or Children who are under the age of eighteen (18) and covered as Insured Persons under this insurance plan.

 

Governing Body or Authority: A nationally-recognized controlling organization for a sport or activity, or an organization that provides guidelines and recommendations in safety practices for a sport or activity.

 

HIV: Human Immunodeficiency Virus, as that term is defined by the United States Centers of Disease Control.

 

HIV +: Laboratory evidence defined by the United States Centers for Disease Control as being positive for Human Immunodeficiency Virus infection.

 

Home Health Care Agency: 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 prescribed by a Physician.

 

Home Nursing Care: Services and/or Treatment provided by a Home Health Care Agency and supervised by a Registered Nurse that are directed toward the Convalescent care of a patient, provided always that such care is Medically Necessary and in lieu of Medically Necessary Inpatient care. Home Nursing Care does not include services or Treatment primarily for Custodial Care or rehabilitative purposes.

 

Hospice; Hospice Care: Care provided in an Inpatient Facility or at a patient’s home.

 

Hospital: An institution which operates as a Hospital pursuant to law; is licensed by the state or country in which it operates; operates primarily for the reception, care, and Treatment of sick or injured persons as Inpatient; provides twenty-four (24) hour nursing service by Registered Nurses on duty or call; has a staff of one (1) or more Physicians available at all times; provides organized Facilities and equipment for diagnosis and Treatment of acute medical or surgical conditions or Mental or Nervous Disorders on its premises; and is not primarily a long-term care Facility, Extended Care Facility, nursing, rest, Custodial Care, convalescent home, place for the aged, drug addicts or abusers, alcoholics or runaways, or similar establishment.

 

Hospitalization; Hospitalized: Confined and/or Treated in a Hospital as an Inpatient.

 

Illness: A sickness, disorder, illness, pathology, abnormality, malady, morbidity, affliction, disability, defect, handicap, deformity, birth defect, congenital defect, symptomatology, syndrome, malaise, infection, infirmity, ailment, disease of any kind, or any other medical, physical or health condition. Provided, however, that Illness does not include learning disabilities, or attitudinal disorders or disciplinary problems. All Illnesses that exist simultaneously or which arise subsequent to a prior Illness and which directly or indirectly relate to or result or arise from the same or related causes or as a consequence thereof or from one another are considered to be a single Illness. Further, if a subsequent Illness results or arises from causes or consequences that are the same as or related to the causes or consequences of a prior Illness, the subsequent Illness will be deemed to be a continuation of the prior Illness and not a separate Illness.

Implant: Any device, object, or medical item that is surgically imbedded, inserted, or installed for medical purposes within or on a patient’s body, including for orthotic or prosthetic reasons.

 

Initial Effective Date: The date the Insured Person originally obtains coverage under this insurance plan and maintains continuous unbroken coverage thereafter.

 

Injury: Bodily injury resulting or arising directly from an Accident. All Injuries resulting or arising from the same Accident shall be deemed to be a single Injury.

 

Inpatient: A person who has been admitted to and charged by a Hospital for bed occupancy for purposes of receiving Inpatient Hospital services. Generally, a patient is considered an Inpatient if billed by the Hospital for Charges as an Inpatient, and formally admitted as an Inpatient with the expectation that person will occupy a bed and (a) remain at least overnight or (b) is expected to need Hospital care for twenty-four (24) hours or more.

 

Insured Person: The person named as the Insured Person on the Declaration.

 

Intensive Care Unit: An area or unit of a Hospital that meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations for Special Care Units.

 

Investigational: Treatment that includes drugs, procedures, or services that are still in the clinical stages of evaluation and not yet released for distribution by the US Food and Drug Administration.

 

Local Ambulance Transport; Local Ambulance Expense: Transportation and accompanying Treatment provided by designated, licensed, qualified, professional emergency personnel from the location of an Accident, Injury or acute Illness to a Hospital or other appropriate health care Facility. Local ambulance transport does not include subsequent Interfacility transfers of admitted patients.

 

Master Policy: The applicable Master Policy issued by the Company to the Assured, and under which insurance coverage and benefits are provided by the Company to the Insured Person, subject to the Terms thereof, and as outlined and evidenced by this Certificate and subject to the Terms hereof. The Company, as insurance carrier and underwriter of the Master Policy, is solely liable and responsible for the coverage and benefits provided thereunder.

 

Maximum Limit: The cumulative total dollar amount of benefit payments and/or reimbursements available to an Insured Person under this insurance. When the Maximum Limit is reached, no further benefits, reimbursements or payments will be available under this insurance.

 

Medically Necessary; Medical Necessity: A Treatment, service, medicine or supply which is necessary and appropriate for the diagnosis or Treatment of an Illness or Injury based on generally accepted standards of current medical practice as determined by the Company. By way of example but not limitation, a service, Treatment, medicine or supply will not be considered Medically Necessary or a Medical Necessity if it is provided or obtained only as a convenience to the Insured Person or his/her provider; and/or if it is not necessary or appropriate for the Insured Person's Treatment, diagnosis or symptoms; and/or if it exceeds (in scope, duration or intensity) that level of care which is needed to provide safe, adequate, and appropriate diagnosis or Treatment.

 

Mental or Nervous Disorders: Any mental, nervous, or emotional Illness which generally denotes an Illness of the brain with predominant behavioral symptoms; an Illness of the mind or personality, evidenced by abnormal behavior; or an Illness or disorder of conduct evidenced by socially deviant behavior. Mental or Nervous Disorders include without limitation: psychosis; depression; schizophrenia; bipolar affective disorder; learning disabilities and attitudinal or disciplinary problems; any disease or condition, regardless of whether the cause is organic, that is classified as a Mental Disorder in the current edition of the International Classification of Diseases as published by the U.S. Department of Health and Human Services; and those psychiatric and other mental Illnesses listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders published by the American Psychiatric Association. For purposes of this insurance, Mental or Nervous Disorders does not include Substance Abuse.

Mortal Remains: The bodily remains or ashes of an Insured Person.

 

Newborn: An infant from the moment of birth through the first thirty-one (31) days of life.

 

Outpatient: A person who receives Medically Necessary Treatment by a Physician or other healthcare provider and is not an Inpatient, regardless of the hour that the person arrived at the Hospital, whether a bed was used, or whether the person remained in the Hospital past midnight.

 

Period of Coverage: The maximum period of twelve (12) continuous months including the initial Certificate Period and any extensions.

 

Physician: A duly educated, trained and licensed practitioner of the medical arts. A Physician must be currently and appropriately licensed by the state or country in which the services are provided, and the services must be within the scope of that license, training, experience, competence, and health professions standards of practice.

 

Plan Administrator: The Plan Administrator for this insurance is International Medical Group®, Inc., 2960 North Meridian Street, Indianapolis, Indiana, 46208, Telephone Number +1.317.655.4500, or +1.800.628.4664, Fax Number +1.317.655.4505, Website: http://www.imglobal.com, Email: insurance@imglobal.com. As the Plan Administrator, International Medical Group, Inc., acts solely as the disclosed and authorized agent and representative for and on behalf of the Company, and does not have, and shall not be deemed, considered or alleged to have any, direct, indirect, joint, several, separate, individual, or independent liability, responsibility or obligation of any kind under the Master Policy, the Declaration, any Riders or this Certificate to the Insured Person or to any other person or entity, including without limitation to any Physician, Hospital, Extended Care Facility, Home Health Care Agency, or any other health care or medical service provider or supplier.

 

Pre-certification; Pre-certify: A general determination of Medical Necessity only, made by the Company in reliance and based upon the completeness and accuracy of the information provided by the Insured Person and/or the Insured Person’s healthcare or medical service providers, guardians, Relatives and/or proxies at the time thereof. Pre-certification is not an assurance, authorization, pre-authorization or verification of coverage, a verification of benefits, or a guarantee of payment.

 

Pre-existing Condition: Any Injury, Illness, sickness, disease, or other physical, medical, Mental or Nervous Disorder, condition or ailment that, with reasonable medical certainty, existed at the time of Application or at any time during the three (3) years prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all subsequent, chronic or recurring complications or consequences related thereto or resulting or arising therefrom.

 

Premium: The Premium payments required to effectuate and maintain the Insured Person’s insurance coverage and benefits under this insurance, in the amounts and at the times (“Due Dates”) established by the Company in its sole discretion from time to time.

 

Professional Athletics: A sport activity, including practice, preparation, and actual sporting events, for any individual or organized team that is a member of a recognized professional sports organization; is directly supported or sponsored by a professional team or professional sports organization; is a member of a playing league that is directly supported or sponsored by a professional team or professional sports organization; or has any athlete receiving for his or her participation any kind of payment or compensation, directly or indirectly, from a professional team or professional sports organization.

 

Proof of Claim: Duly completed and signed claim form, authorization to release medical information, Physician, Hospital and other healthcare provider’s statement detailing the cost and services rendered and proof of payment for services rendered. Refer to the CONDITIONS AND GENERAL PROVISIONS, CLAIMS NOTIFICATION, Proof of Claim provision for further details.

 

Radiology: Specialty services that use medical imaging to diagnose and Treat an Illness or Injury seen within the body. Imaging techniques used in Radiology include x-ray, radiography, ultrasound, computed tomography (CT), nuclear medicine, including positron emission tomography (PET), and magnetic resonance imaging (MRI).

 

Registered Nurse: A graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters "R.N." after his or her name.

 

Relative: A parent, legal guardian, Spouse, son, daughter, or immediate Family member of the Insured Person.

 

Rider: Any exhibit, schedule, attachment, amendment, endorsement, Rider or other document attached to, issued in connection with, or otherwise expressly made a part of or applicable to, the Master Policy, this Certificate, the Declaration, or the Application, as the case may be.

 

Routine Physical Examination: Examination of the physical body by a Physician for preventative or informative purposes only, and not for the Treatment of any previously manifested, symptomatic, diagnosed or known Illness or Injury.

Self-inflicted: Action or inaction by the Insured Person that the Insured Person consciously understands will or may cause or contribute, directly or indirectly, to his or her personal Injury or Illness. Self-inflicted specifically includes failure of an Insured Person to follow his or her doctor’s orders, complete prescriptions as directed, or follow any health care protocol or procedures designed to return or maintain his or her health.

 

Spouse: An Insured Person’s legal Spouse. Such Spouse must have met all requirements of a valid marriage contract in the Country of Residence of such parties. The term “Spouse” shall exclude: a Spouse who is legally separated or divorced from the Insured Person so long as all requirements have been met of a valid separation agreement or divorce decree in the state granting such separation or divorce; and/or Spouse who is on active military duty; and/or a Spouse who is covered under this insurance as an Insured Person.

 

Substance Abuse: Alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency.

 

Sudden and Unexpected Reoccurrence of a Pre-existing Condition: A sudden and unexpected outbreak or reoccurrence of a Pre-existing Condition is a condition:

(a) that 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 medical care

(b) that occurs after the Effective Date

(c) for which Treatment must be obtained within twenty-four (24) hours of the sudden and unexpected outbreak or reoccurrence.

A Pre-existing Condition is not a Sudden and Unexpected Reoccurrence of a Pre-existing Condition where:

(a) the Pre-existing Condition is chronic, congenital or a condition that gradually becomes worse over time

(b) medical care, drugs or Treatments were received, expected, scheduled, or required thirty (30) days prior to the Effective Date.

 

Surgery; Surgical Procedure: An invasive diagnostic or surgical 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.

 

Telemedicine: The use of medical information (beyond a verbal history) exchanged from one healthcare provider site to another via electronic communications to improve patients' health status. Videoconferencing, transmission of still images, and remote monitoring of vital signs are all considered part of Telemedicine. Telemedicine services that would be considered for Medical Necessity and appropriateness by the Company under the plan would include without limitation:

(a) Specialist referral services which typically involve a specialist assisting a general practitioner in rendering a diagnosis to guide Treatment.

(b) Patient consultations using telecommunications to provide medical data, which may include audio, still or live images, between a patient and a Physician or other healthcare provider for use in rendering a diagnosis and Treatment plan. This might originate from a remote clinic to a Physician's office using a direct transmission link or may include communicating electronically.

(c) Remote patient monitoring using devices to remotely collect and send data from a medical Facility to a monitoring station for interpretation. Such applications might include a specific vital sign, such as blood glucose or heart ECG.

 

Terms: All Terms, provisions, conditions, definitions, Deductibles, Coinsurance, limits, sub-limits, limitations, wordings, restrictions, requirements, qualifications and/or exclusions that bind the Insured Person as set forth in the Master Policy, Application and any Riders.

 

Terrorism: Criminal acts, including against civilians, committed with the intent to cause death or serious bodily injury, or taking of hostages, with the purpose to provide a state of terror in the general public or in a group of persons or particular persons, intimidate a population, or compel a government or international organization to do or to abstain from doing an act.

 

Travel Warning; Emergency Travel Advisory: Published statement or website document issued by the United States Department of State, Bureau of Consular Affairs, Centers for Disease Control and Prevention, United Nations, World Health Organization or similar government or non-governmental agency of the Insured Person’s Country of Residence, warning that travel to specific identified countries, regions or locations poses serious risks to safety and security or exposes the Insured Person to a greater likelihood of life-threatening risks, including but not limited to United States Department of State Travel Advisories levels "3 - Reconsider travel" and "4 - Do not travel."

 

Treated; Treatment: Any and all services and procedures rendered in the management and/or care of a patient for the purpose of identifying, diagnosing, treating, curing, preventing, controlling and/or combating any Illness or Injury, including without limitation: verbal or written advice, consultation, examination, discussion, diagnostic testing or evaluation of any kind, pharmacotherapy or other medication, and/or Surgery.

 

Unexpected: Sudden, unintentional, not expected and unforeseen.

 

Urgent Care Clinic: A standalone Facility or a Facility located inside a Hospital that staffs Physicians, nurse practitioners (NP) or physician assistants (PA). Urgent Care Clinics provide medical services that are not life-threatening Injuries or Illnesses. Urgent Care Facilities have onsite x-ray equipment and provide Treatment for more severe urgent care services such as broken bones, burns and other non-emergent conditions that Walk-in Clinics are unable to treat.

 

Usual, Reasonable and Customary: A typical and reasonable amount of reimbursement for similar services, medicines, or supplies within the area in which the Charge is incurred. In determining the typical and reasonable amount of reimbursement, the Company may, in its reasonable discretion, consider one or more of the following factors, without limitation: the amount charged by the provider; the amount charged by similar providers or providers in the same or similar locality; the amount reimbursed by other payors for the same or comparable services, medicines or supplies in the same or similar locality; whether the services or supplies were unbundled or should have been included in the allowance of another service; the amount reimbursed by other payors 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; 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 service as compared to the length of time required to perform other similar services; the length of time required to perform the procedure or service as compared to national standards and/or benchmarks; the severity or nature of the Illness or Injury being Treated; and such other factors as the Company, in the reasonable exercise of its discretion, determines are appropriate

 

BENEFIT SUMMARY – PLAN A

Coverage Limit / Maximum Amount for Eligible Medical Expenses

Period of Coverage

Twelve (12) continuous months of maximum coverage

Certificate Period

Refer to the Declaration page for the Effective and termination dates of coverage

Lifetime Maximum Limit

Age 15 days - 79 years of age: $25,000

Age 80 years of age and older: $10,000

Area of Coverage

Worldwide excluding Country of Residence

Deductible for Eligible Medical Expenses

Per Certificate Period up to the Maximum Period of Coverage

 

Deductible

Refer to the Declaration page

Coinsurance for Eligible Medical Expenses

Per Certificate Period up to the Maximum Period of Coverage

 

Coinsurance

Plan Pays: 100% of scheduled Benefit Limit

The insured is responsible for Charges that are not considered Eligible Medical

Expenses and exceed the Maximum Limits stated in the Inpatient Services, Outpatient

Services, Emergency Services, and Other Services sections of this Benefit Summary

Pre-existing Condition

Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance.

Acute Onset of Pre-existing Condition

Subject to any and all scheduled benefits, daily limits and/or sub-limits

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

Benefit

Limits

Acute Onset of Pre-existing Conditions

 Insured Person must be under 70 years of age

 Refer to the ACUTE ONSET OF PRE-EXISTING CONDITIONS provision for further details and requirements

Maximum Limit: $25,000

 

Emergency Medical Evacuation

 Arises or results directly from a covered Acute Onset of a Pre-existing Condition

 Insured Person must be under 70 years of age

 

Maximum Limit: $25,000

 

 

Pre-certification

 

> Medical Evacuation: No coverage if not approved by the Company. Refer to the MEDICAL EVACUATION provision for

complete requirements and coverage.

> If Treatments & supplies are not pre-certified, Eligible Medical Expenses will be reduced by fifty percent (50%). Refer to

the PRE-CERTIFICATION REQUIREMENTS, SPECIFIC REQUIREMENTS, provision for a complete list of services that

require pre-certification.

> Deductible is taken after reduction.

> Coinsurance is applied to remainder of the reduced amount.

Inpatient Services

Subject to Deductible and Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

Benefit

Limits

Inpatient Physician

> Visit Limit: 1 per day

> Maximum Visit Limit: 30

Maximum per Day Visit: $40

Specialist Consultation

> Must be ordered by attending Physician

Maximum Limit: $350

Hospital / Room & Board

> Average semi-private room rate

> Includes miscellaneous Charges and Ancillary Services

> Maximum Days: 30

Maximum per Day: $825

Intensive Care

> Maximum Days: 8

Additional Benefit per Day: $400

Private Duty Nursing

Maximum Limit: $400

Surgeon

Maximum per Surgical Session: $2,000

Assistant Surgeon

Maximum per Surgical Session: $450

Anesthesia

Maximum per Surgical Session: $450

Chemotherapy and Radiation Therapy

Maximum Limit: $550

Outpatient Services

Subject to Deductible and Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Pre-admission Testing

Maximum Limit: $750

Outpatient Physician

> Daily Visit Limit: 1

> Maximum Visit Limit: 10

Maximum per Visit: $50

Urgent Care Clinic

§ Maximum visits: 10

Maximum per visit: $40

Diagnostic Laboratory and Radiology

Maximum per procedure: $200

 

Maximum Limit: $400

Hospital Emergency Room

Maximum per Visit: $200

Surgical Facility

Maximum per Surgical Session: $750

Surgeon

Maximum per Surgical Session: $2,000

Assistant Surgeon

Maximum per Surgical Session: $450

Anesthesia

Maximum per Surgical Session: $450

Chemotherapy and Radiation Therapy

Maximum Limit: $550

Home Nursing Care

§ Provided by a Home Health Care Agency

§ Upon direct transfer from an acute care Facility

Maximum Limit: $550

 

Physical Therapy:

> Daily Visit Limit: 1

> Maximum Visit Limit: 12

Maximum per Visit: $40

Extended Care Facility

> Maximum Days: 15

> Upon direct transfer from acute care Hospital

Maximum Limit: $150

Durable Medical Equipment

Maximum Limit: $550

Prescriptions

Maximum Limit: $250

Emergency Services

NOT Subject to Deductible or Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Common Carrier Accidental Death

Maximum Limit: $25,000

 

Emergency Local Ambulance

> Subject to Deductible

> Injury

> Illness resulting in a Hospitalization admission

Maximum Limit: $250

Emergency Services

NOT Subject to Deductible or Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Benefit

Limits

Emergency Medical Evacuation

> Approved in advance and Coordinated by the Company

> Not subject to Period of Coverage Maximum Limit

Maximum Limit: $25,000

Return of Mortal Remains

> Return of Insured Person’s Mortal Remains to Country of

Residence

> Approved in advance and Coordinated by the Company

Maximum Limit: $25,000

Local Burial/Cremation Maximum Limit: $5,000

Other Services

NOT Subject to Deductible or Coinsurance unless otherwise noted.

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Dental Accident

> Subject to Deductible

Maximum Limit: $550

Incidental Home Country Coverage

Maximum Days Limit: 14

Terrorism

> Not subject to Deductible

Maximum Limit: $50,000

BENEFIT SUMMARY – PLAN B

Coverage Limit / Maximum Amount for Eligible Medical Expenses

Period of Coverage

Twelve (12) continuous months of maximum coverage

Certificate Period

Refer to the Declaration page for the Effective and termination dates of coverage

Period of Coverage per Injury or Illness Maximum Limit

$50,000

 

Age Limit

 

Age 14 days - 79 years of age

Area of Coverage

Worldwide excluding Country of Residence

Deductible for Eligible Medical Expenses

Per Certificate Period up to the Maximum Period of Coverage

 

Deductible

Refer to the Declaration page

Coinsurance for Eligible Medical Expenses

Per Certificate Period up to the Maximum Period of Coverage

 

Coinsurance

Plan Pays: 100% of scheduled Benefit Limit

The insured is responsible for Charges that are not considered Eligible Medical

Expenses and exceed the Maximum Limits stated in the Inpatient Services, Outpatient

Services, Emergency Services, and Other Services sections of this Benefit Summary

Pre-existing Condition

Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance.

Acute Onset of Pre-existing Condition

Subject to any and all scheduled benefits, daily limits and/or sub-limits

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

Benefit

Limits

Acute Onset of Pre-existing Conditions

Insured Person must be under 70 years of age

Refer to the ACUTE ONSET OF PRE-EXISTING CONDITIONS provision for further details and requirements

Maximum Limit: $50,000

 

Emergency Medical Evacuation

 Arises or results directly from a covered Acute Onset of a Pre-existing Condition

 Insured Person must be under 70 years of age

 

Maximum Limit: $25,000

 

 

Pre-certification

 

> Medical Evacuation: No coverage if not approved by the Company. Refer to the MEDICAL EVACUATION provision for

complete requirements and coverage.

> If Treatments & supplies are not pre-certified, Eligible Medical Expenses will be reduced by fifty percent (50%). Refer to

the PRE-CERTIFICATION REQUIREMENTS, SPECIFIC REQUIREMENTS, provision for a complete list of services that

require pre-certification.

> Deductible is taken after reduction.

> Coinsurance is applied to remainder of the reduced amount.

Inpatient Services

Subject to Deductible and Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

Benefit

Limits

Inpatient Physician

> Visit Limit: 1 per day

> Maximum Visit Limit: 30

Maximum per Day Visit: $60

Specialist Consultation

> Must be ordered by attending Physician

Maximum Limit: $450

Hospital / Room & Board

> Average semi-private room rate

> Includes miscellaneous Charges and Ancillary Services

> Maximum Days: 30

Maximum per Day: $1400

Intensive Care

> Maximum Days: 8

Additional Benefit per Day: $660

Private Duty Nursing

Maximum Limit: $550

Surgeon

Maximum per Surgical Session: $3,300

Assistant Surgeon

Maximum per Surgical Session: $825

Anesthesia

Maximum per Surgical Session: $825

Chemotherapy and Radiation Therapy

Maximum Limit: $1,100

Outpatient Services

Subject to Deductible and Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Pre-admission Testing

Maximum Limit: $1,100

Outpatient Physician

> Daily Visit Limit: 1

> Maximum Visit Limit: 10

Maximum per Visit: $60

Urgent Care Clinic

§ Maximum visits: 10

Maximum per visit: $60

Diagnostic Laboratory and Radiology

Maximum per procedure: $250

 

Maximum Limit: $450

Hospital Emergency Room

Maximum per Visit: $330

Surgical Facility

Maximum per Surgical Session: $900

Surgeon

Maximum per Surgical Session: $3,300

Assistant Surgeon

Maximum per Surgical Session: $825

Anesthesia

Maximum per Surgical Session: $825

Chemotherapy and Radiation Therapy

Maximum Limit: $1,100

Home Nursing Care

§ Provided by a Home Health Care Agency

§ Upon direct transfer from an acute care Facility

Maximum Limit: $550

 

Physical Therapy:

> Daily Visit Limit: 1

> Maximum Visit Limit: 12

Maximum per Visit: $40

Durable Medical Equipment

Maximum Limit: $1,000

Prescriptions

• Dispensing limit per prescription: 90 days

Maximum Limit: $250

Emergency Services

NOT Subject to Deductible or Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Common Carrier Accidental Death

Maximum Limit: $25,000

 

Emergency Local Ambulance

> Subject to Deductible

> Injury

> Illness resulting in a Hospitalization admission

Maximum Limit: $450

Emergency Services

NOT Subject to Deductible or Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Benefit

Limits

Emergency Medical Evacuation

> Approved in advance and Coordinated by the Company

> Not subject to Period of Coverage Maximum Limit

Maximum Limit: $50,000

Return of Mortal Remains

> Return of Insured Person’s Mortal Remains to Country of

Residence

> Approved in advance and Coordinated by the Company

Maximum Limit: $25,000

Local Burial/Cremation Maximum Limit: $5,000

Other Services

NOT Subject to Deductible or Coinsurance unless otherwise noted.

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Dental Accident

> Subject to Deductible

Maximum Limit: $550

Incidental Home Country Coverage

Maximum Days Limit: 14

Terrorism

> Not subject to Deductible

Maximum Limit: $50,000

 

BENEFIT SUMMARY – PLAN C

Coverage Limit / Maximum Amount for Eligible Medical Expenses

Period of Coverage

Twelve (12) continuous months of maximum coverage

Certificate Period

Refer to the Declaration page for the Effective and termination dates of coverage

Period of Coverage per Injury or Illness Maximum Limit

$100,000

 

Age Limit

 

Age 14 days - 79 years of age

Area of Coverage

Worldwide excluding Country of Residence

Deductible for Eligible Medical Expenses

Per Certificate Period up to the Maximum Period of Coverage

 

Deductible

Refer to the Declaration page

Coinsurance for Eligible Medical Expenses

Per Certificate Period up to the Maximum Period of Coverage

 

Coinsurance

Plan Pays: 100% of scheduled Benefit Limit

The insured is responsible for Charges that are not considered Eligible Medical

Expenses and exceed the Maximum Limits stated in the Inpatient Services, Outpatient

Services, Emergency Services, and Other Services sections of this Benefit Summary

Pre-existing Condition

Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance.

Acute Onset of Pre-existing Condition

Subject to any and all scheduled benefits, daily limits and/or sub-limits

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

Benefit

Limits

Acute Onset of Pre-existing Conditions

Insured Person must be under 70 years of age

Refer to the ACUTE ONSET OF PRE-EXISTING CONDITIONS provision for further details and requirements

Maximum Limit: $100,000

 

Emergency Medical Evacuation

Arises or results directly from a covered Acute Onset of a Pre-existing Condition

Insured Person must be under 70 years of age

 

Maximum Limit: $25,000

 

 

Pre-certification

 

> Medical Evacuation: No coverage if not approved by the Company. Refer to the MEDICAL EVACUATION provision for

complete requirements and coverage.

> If Treatments & supplies are not pre-certified, Eligible Medical Expenses will be reduced by fifty percent (50%). Refer to

the PRE-CERTIFICATION REQUIREMENTS, SPECIFIC REQUIREMENTS, provision for a complete list of services that

require pre-certification.

> Deductible is taken after reduction.

> Coinsurance is applied to remainder of the reduced amount.

Inpatient Services

Subject to Deductible and Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

Benefit

Limits

Inpatient Physician

> Visit Limit: 1 per day

> Maximum Visit Limit: 30

Maximum per Day Visit: $85

Specialist Consultation

> Must be ordered by attending Physician

Maximum Limit: $500

Hospital / Room & Board

> Average semi-private room rate

> Includes miscellaneous Charges and Ancillary Services

> Maximum Days: 30

Maximum per Day: $2000

Intensive Care

> Maximum Days: 8

Additional Benefit per Day: $850

Private Duty Nursing

Maximum Limit: $550

Surgeon

Maximum per Surgical Session: $5,500

Assistant Surgeon

Maximum per Surgical Session: $1,375

Anesthesia

Maximum per Surgical Session: $1,375

Chemotherapy and Radiation Therapy

Maximum Limit: $1,350

Outpatient Services

Subject to Deductible and Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Pre-admission Testing

Maximum Limit: $1,100

Outpatient Physician

> Daily Visit Limit: 1

> Maximum Visit Limit: 10

Maximum per Visit: $85

Urgent Care Clinic

§ Maximum visits: 10

Maximum per visit: $85

Diagnostic Laboratory and Radiology

Maximum per procedure: $500

 

Maximum Limit: $500

Hospital Emergency Room

Maximum per Visit: $550

Surgical Facility

Maximum per Surgical Session: $1000

Surgeon

Maximum per Surgical Session: $5,500

Assistant Surgeon

Maximum per Surgical Session: $1,375

Anesthesia

Maximum per Surgical Session: $1,375

Chemotherapy and Radiation Therapy

Maximum Limit: $1,350

Home Nursing Care

§ Provided by a Home Health Care Agency

§ Upon direct transfer from an acute care Facility

Maximum Limit: $550

 

Physical Therapy:

> Daily Visit Limit: 1

> Maximum Visit Limit: 12

Maximum per Visit: $40

Durable Medical Equipment

Maximum Limit: $1,300

Prescriptions

• Dispensing limit per prescription: 90 days

Maximum Limit: $250

Emergency Services

NOT Subject to Deductible or Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Common Carrier Accidental Death

Maximum Limit: $25,000

 

Emergency Local Ambulance

> Subject to Deductible

> Injury

> Illness resulting in a Hospitalization admission

Maximum Limit: $475

Emergency Services

NOT Subject to Deductible or Coinsurance unless otherwise noted

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Benefit

Limits

Emergency Medical Evacuation

> Approved in advance and Coordinated by the Company

> Not subject to Period of Coverage Maximum Limit

Maximum Limit: $50,000

Return of Mortal Remains

> Return of Insured Person’s Mortal Remains to Country of

Residence

> Approved in advance and Coordinated by the Company

Maximum Limit: $25,000

Local Burial/Cremation Maximum Limit: $5,000

Other Services

NOT Subject to Deductible or Coinsurance unless otherwise noted.

Charges are Subject to Usual, Reasonable, and Customary

Limits per Certificate Period up to the Maximum Period of Coverage

 

Dental Accident

> Subject to Deductible

Maximum Limit: $550

Incidental Home Country Coverage

Maximum Days Limit: 14

Terrorism

> Not subject to Deductible

Maximum Limit: $50,000

 

BENEFIT PERIOD AND HOME COUNTRY COVERAGE

SCHEDULE OF BENEFITS / BENEFIT SUMMARY: Subject to the Terms of this insurance and the insurance plan shown in the Declaration, the insurance plan is available to the Insured Person while outside his/her Home Country and offers benefits and coverage arising out of Injury or Illness incurred while the insurance plan shown in the Declaration is in effect.

Home Country: For United States citizens, the Home Country is the United States. For non-United States citizens, the Home Country is the country of which the Insured Person is a citizen or national; including any country where the Insured Person maintains his/her primary residence or usual place of abode and any country of which the Insured Person pays income taxes or is the possessor of a validly issued passport. In the event there is more than one Home Country under the above-listed criteria or the person has dual citizenship, the Home Country is the country meeting the above-listed criteria and listed by the Insured Person as his or her Home Country on the Application.

INCIDENTAL HOME COUNTRY COVERAGE: As an accommodation and supplemental benefit, the Insured Person will be covered under this insurance during incidental return trips to his/her Home Country (“Incidental Trips”) up to fourteen (14) days during the Period of Coverage, beginning with the date the Insured Person first arrives back in his/her Home Country, provided:

(1) the Insured Person has departed his/her Home Country prior to any Incidental Trip; and

(2) the Insured Person has timely paid applicable Premium for at least thirty (30) days of continuous coverage; and

(3) the intention or purpose of the Insured Person’s return trip to the Home Country is not to receive Treatment for an Illness or Injury incurred or sustained while traveling outside of his/her Home Country; and

(4) the Insured Person’s return trip to the Home Country does not result in receiving Treatment for an Illness or Injury incurred or sustained while traveling outside of his/her Home Country.

Pre-existing Condition

Any Injury, Illness, sickness, disease, or other physical, medical, Mental or Nervous Disorder, condition or ailment that, with reasonable medical certainty, existed at the time of Application or at any time during the three (3) years prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all subsequent, chronic or recurring complications or consequences related thereto or resulting or arising therefrom.

 

ELIGIBLE MEDICAL EXPENSES

 

Subject to the Terms of this insurance, and the insurance plan shown in the Declaration, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY for the following costs, Charges and expenses incurred by the Insured Person during the Certificate Period with respect to an Illness or Injury suffered or sustained by the Insured Person during the Certificate Period and while this Certificate is in effect, so long as the Illness or Injury is covered under this Certificate, Charges are Usual, Reasonable and Customary, and Charges are incurred for Treatment or supplies that are Medically Necessary (“Eligible Medical Expenses”):

(1) Charges incurred at a Hospital for Inpatient Treatment:

(a) daily room and board, nursing services, Ancillary Services including the use of the observation, operating, Treatment or recovery room

(b) daily room and board, nursing services and Ancillary Services in an Intensive Care Unit

(c) Extended Care Facility following an acute Hospital Inpatient stay are to be included in the per day Hospital room and board limits shown in the BENEFIT SUMMARY

(d) services and supplies that are routinely provided by the Hospital to persons for use while an Inpatient including medications and to be included in the per day Hospital room and board limits shown in the BENEFIT SUMMARY

(e) Surgery including services and supplies

(f) Inpatient Physician and specialist consultation visits

(g) surgeon and assistant surgeon including services and supplies

(h) anesthetics and their administration by a Physician

(i) private duty nursing

 

(2) Charges incurred for Surgery at an Outpatient Surgical Facility, including services and supplies

 

(3) Charges incurred for Outpatient Treatment:

(a) Emergency Treatment of an Injury, even if Hospital confinement is not required

(b) Emergency Treatment of an Illness; however, Charges for use of the Emergency room itself will not be covered unless the Insured Person is directly admitted to the Hospital as Inpatient for further Treatment of that Illness

(c) Emergency Local Ambulance Transport necessarily incurred in connection with: (i) an Injury

(ii) an Illness resulting in Hospital confinement as an Inpatient

(d) dressings, sutures, casts or other supplies that are Medically Necessary to be included in Physician visits

(e) diagnostic testing using Radiology, ultrasonography or laboratory services. Laboratory services billed for professional component fees are covered if the pathologist has direct involvement in providing a written report or verbal consultation for specimen-specific pathology services

(f) pre-admission testing

(g) Outpatient Physician visit

(h) Telemedicine consultations through an established Telemedicine protocol system will be considered individually based on medical necessity and appropriateness as determined by the Company under the plan subject to the Outpatient Physician Maximum Limits shown in the BENEFIT SUMMARY

(i) surgeon and assistant surgeon including services and supplies

(j) anesthetics and their administration by a Physician

(k) radiation therapy or Treatment, and chemotherapy

(l) drugs that require a prescription by a Physician for Treatment of Illness or Injury, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of ninety (90) days of any one (1) prescription

(m) Home Nursing Care in bed by a qualified licensed professional, provided by a Home Health Care Agency upon direct transfer from an acute care Hospital

(n) Durable Medical Equipment, as defined herein, deemed to be Medically Necessary

(o) physical therapy prescribed by a Physician and performed by a professional physical therapist and necessarily incurred to continue recovery from a covered Injury or covered Illness

(p) Emergency Dental Treatment and Dental Surgery necessary to restore or replace sound natural teeth lost or damaged in an Accident that is covered under this insurance.

 

 

COMMON CARRIER ACCIDENTAL DEATH

 

Subject to the Terms of this insurance, including the EXCLUSIONS provision, and in the event of an Unexpected death of an Insured Person during the Certificate Period as a result of an Accident that occurred during the Certificate Period and while the Insured Person was traveling on a Common Carrier, the Company will reimburse a Common Carrier Accidental Death benefit up to the amount shown in the BENEFIT SUMMARY provided, however, that such Common Carrier Accidental Death benefits shall not exceed the maximum amount shown in the BENEFIT SUMMARY per Family involved in the same Accident. (1) The Company will pay the benefit owed, upon proper application therefor, in the following order: (a) to the beneficiary designated in writing by the Insured Person

(b) to the Insured Person’s closest surviving Relative

(c) the Insured Person’s estate

(d) to a claimant entitled to payment under applicable small estate affidavit laws.

 

 

EMERGENCY MEDICAL EVACUATION

 

(1) Subject to the Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and the CONDITIONS AND RESTRICTIONS subparagraphs below, the Company will reimburse the Insured Person for the following transportation costs when the Company or Plan Administrator arranges such transportation and expenses incurred by the Insured Person arising out of or in connection with an Emergency Medical Evacuation outside the Insured Person’s Home Country during the Certificate Period: (a) Emergency air transportation to a suitable airport nearest to the Hospital where the Insured Person will receive Treatment

(b) Emergency ground transportation necessarily preceding Emergency air transportation and from the destination airport to the Hospital where the Insured Person will receive Treatment

(c) Return ground and air transportation, upon medical release by the attending Physician, to the country where the evacuation initially occurred or to the Insured Person’s Country of Residence, at the Insured Person’s option.

 

 

CONDITIONS AND RESTRICTIONS: To be eligible for coverage for Emergency Medical Evacuation benefits, the Insured Person must be in compliance with all Terms of this insurance. The Company will provide Emergency Medical Evacuation benefits only when the condition, Illness, Injury or occurrence giving rise to the Emergency Medical Evacuation is covered under the Terms of this insurance. The Company will provide Emergency Medical Evacuation benefits only when all of the following conditions and restrictions are met: (a) The Company will provide Emergency Medical Evacuation benefits only when the Insured Person is outside his/her Country of Residence when the condition giving rise to the Emergency Medical Evacuation arises. The Company will not provide Emergency Medical Evacuation from the Insured Person’s Country of Residence to any other country, or to another location within the Insured Person’s Country of Residence

(b) Medically Necessary Treatment cannot be provided locally

(c) transportation by any other means or methods would result in loss of the Insured Person’s life or limb within twenty-four (24) hours, based upon a reasonable medical certainty

(d) Emergency Medical Evacuation is recommended by the attending Physician who certifies to the matters in subparagraphs (a) and (b), above

(e) Emergency Medical Evacuation is agreed to by the Insured Person or a Relative of the Insured Person

(f) Emergency Medical Evacuation is provided by designated, licensed, qualified, professional emergency personnel acting within the scope of such license and approved in advance and all arrangements are coordinated by the Company

(g) the condition, Illness, Injury or occurrence giving rise to the need for the Emergency Medical Evacuation: (i) occurred outside the Insured Person’s Country of Residence suddenly, Unexpectedly, and spontaneously, and without: (1) advance warning, or (2) advance Treatment, diagnosis or recommendation for Treatment by a Physician, or (3) prior manifestation of symptoms or conditions that would have caused a reasonably prudent person to seek medical attention prior to the onset of the Emergency

(ii) was not a Pre-existing Condition.

 

The Company will cover reimbursement for the above-described costs and expenses and will arrange Emergency Medical Evacuation only to the nearest Hospital that is qualified to provide the Medically Necessary Treatment to prevent the Insured Person's loss of life or limb.

 

The Insured Person may select a different Hospital in his/her Country of Residence at his/her option, but in such event the Insured Person shall be solely responsible for all costs and expenses in excess of the amounts that would have been incurred had the Insured Person used the nearest qualified Hospital. If a Hospital other than the nearest qualified Hospital is selected by the Insured Person, then the attending Physician, Insured Person or a Relative of the Insured Person shall certify to the Company the Insured Person’s understanding and acknowledgement of such responsibility for excess costs and expenses in addition to the matters set forth in the CONDITIONS AND RESTRICTIONS subparagraph, above. In all cases the Company will make the necessary arrangements for the Emergency Medical Evacuation and will use its best efforts to arrange with independent, third-party contractors any Emergency Medical Evacuation within the least amount of time reasonably possible.

 

By acceptance of this Certificate and request for Emergency Medical Evacuation benefits hereunder, the Insured Person understands, acknowledges and agrees that the timeliness, duration, occurrences during and outcome of an Emergency Medical Evacuation can be directly and indirectly affected by events and/or circumstances that are not within the supervision or control of the Company, including but not limited to: the availability, limitations, physical condition, reliability, maintenance and training schedules and procedures and performance or non-performance of competent transportation equipment, supplies and/or staff of such third-party contractors; delays or restrictions on flights or other modes or means of transportation caused by mechanical problems, government officials, telecommunications problems, non-availability of routes, and/or other travel, geographical or weather conditions; and other acts of God and unforeseeable and/or uncontrollable occurrences.

 

The Insured Person agrees to release and to hold the Company, the Plan Administrator and their agents and representatives harmless from, and agrees that the Company, the Plan Administrator and their agents and representatives shall not be held liable or responsible for, any delays, losses, damages, further Injuries or Illnesses or any other claims that arise from or are caused in whole or in part by the acts or omissions of such independent third-party contractors or their agents, employees or representatives, or that arise from or are caused in whole or in part by any acts, omissions, events or circumstances that are not within the direct and immediate supervision and control of the Company, the Plan Administrator and/or their authorized agents and representatives, including without limitation the events and circumstances set forth above.

 

The Insured Person further agrees that upon seeking an Emergency Medical Evacuation, he or she will cooperate fully as required by the CONDITIONS AND GENERAL PROVISIONS, COOPERATION provision. Failure to so cooperate and/or failure to use or accept Emergency Medical Evacuation once it has been arranged by the Company or Plan Administrator will require the Insured Person to reimburse the Company for costs incurred for any Emergency Medical Evacuation that was arranged, but not used, by the Insured Person. Furthermore, the Insured Person may be required to arrange for payment of any subsequent Emergency Medical Evacuation and seek reimbursement thereafter for eligible costs associated with that subsequent Emergency Medical Evacuation.

 

INCIDENTAL TRIP: As an accommodation and supplemental benefit and subject to the Terms of this insurance, the Insured Person will be covered under this insurance during incidental return trips to his/her Country of Residence up to the number of days shown in the BENEFIT SUMMARY during the Certificate Period beginning with the date the Insured Person first arrives back in his/her Country of Residence provided that:

(1) the Insured Person has departed his/her Country of Residence prior to any Incidental Trip

(2) the Insured Person has timely paid applicable Premium for at least thirty (30) days of continuous coverage

(3) the intention or purpose of the Insured Person’s return trip to the Country of Residence is not to receive Treatment for an Illness or Injury incurred or sustained while traveling outside of his/her Country of Residence

(4) the Insured Person’s return trip to the Country of Residence does not result in receiving Treatment for an Illness or Injury incurred or sustained while traveling outside of his/her Country of Residence.

RETURN OF MORTAL REMAINS: In the event of the death of the Insured Person during the Certificate Period as a result of an Illness or Injury covered under this insurance while the Insured Person is outside of his/her Country of Residence, the Company will reimburse the authorized personal representative or the estate of the Insured Person up to the amount shown in the BENEFIT SUMMARY for the costs and expenses incurred to return the Insured Person's Mortal Remains to his/her Country of Residence and thereafter to the place of burial or other final disposition (but not including any costs of burial or other disposition); provided, however, that the Company must approve all costs and expenses related to the return of the Insured Person's Mortal Remains in advance as a condition to the availability of this benefit; or up to the amount shown in the BENEFIT SUMMARY for preparation, local burial or cremation of the Insured Person’s Mortal Remains at the place of death in accordance with the commonly accepted cultural and religious beliefs practiced by the Insured Person. Coverage is not provided for burial and cremation costs incurred for religious practitioners, flowers, music, food or beverages.

 

 

                                                                                                EXCLUSIONS

 

Except as expressly provided for in the BENEFIT SUMMARY, all Charges, costs, expenses and/or claims incurred by the Insured Person, and directly or indirectly relating to or arising or resulting from or in connection with any of the following acts, omissions, events, conditions, Charges, consequences, claims, Treatment (including diagnoses, consultations, tests, examinations and evaluations related thereto), services and/or supplies are expressly excluded from coverage under this insurance, and the Company shall provide no benefits or reimbursements and shall have no liability or obligation for any coverage thereof or therefor:

 

(1) WAR; MILITARY ACTION; TERRORISM: The Company shall not be liable for and will not provide coverage or benefits for any claim or Charges incurred with respect to any Illness, Injury, or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising or incurred in connection with or as a result of the Insured Person’s active and voluntary planning or coordination of or participation in any of the following acts or event occurrences: (a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war

(b) mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power

(c) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege

(d) any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by violence of any type

(e) any use of radiological, chemical, nuclear or biological weapons or any other radiological, chemical, nuclear or biological events of any type (including in connection with an act of Terrorism)

(f) any act of Terrorism.

 

 

Any claim, Charges, Illness, Injury or other consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether or not directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said occurrences shall be deemed and considered to be consequences for which the Company shall not be liable under the Master Policy or this Certificate, except to the extent that the Insured Person shall prove that he/she was a victim, innocent bystander, and there was no contributory fault chargeable to the Insured Person.

 

(2) PRE-EXISTING CONDITIONS: Charges resulting directly or indirectly from or relating to any Pre-existing Condition, defined as a medical or health condition (whether physical or mental, regardless of the cause of the condition) are excluded from coverage under this insurance

 

(3) MATERNITY AND NEWBORN CARE: Charges for pre-natal care, delivery, post-natal care, and care of Newborns, including complications of Pregnancy, miscarriage, complications of delivery and/or of Newborns are excluded from this insurance

 

(4) MENTAL OR NERVOUS DISORDERS: Charges for Treatment of Mental or Nervous Disorders are excluded from coverage under this insurance.

 

(5) PREVENTATIVE CARE: Charges for Routine Physical Examinations and immunizations are excluded from coverage under this insurance

 

(6) Charges for any Treatment or supplies that are: (a) not incurred, obtained or received by an Insured Person during the Certificate Period

(b) not presented to the Company for payment by way of a completed Proof of Claim within one hundred eighty (180) days from the date such Charges are incurred

(c) not administered or ordered by a Physician

 (d) not Medically Necessary for the diagnosis, care or Treatment of the physical or mental condition involved. This also applies when and if they are prescribed, recommended or approved by the attending Physician

(e) provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable

(f) in excess of Usual, Reasonable and Customary

(g) related to Hospice Care

(h) incurred by an Insured Person who was HIV + on or before the Initial Effective Date of this insurance, whether or not the Insured Person had knowledge of his/her HIV status prior to the Effective Date, and whether or not the Charges are incurred in relation to or as a result of said status. This exclusion includes Charges for any Treatment or supplies relating to or arising or resulting directly or indirectly from HIV, AIDS virus, AIDS related Illness, ARC Syndrome, AIDS and/or any other Illness arising or resulting from any complications or consequences of any of the foregoing conditions

(i) provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician

(j) performed or provided by a Relative of the Insured Person

(k) not expressly included in the ELIGIBLE MEDICAL EXPENSES provision

(l) provided by a person who resides or has resided with the Insured Person or in the Insured Person's home

(m) required or recommended as a result of complications or consequences arising from or related to any Treatment, Illness, Injury, or supply excluded from coverage or which is otherwise not covered under this insurance

(n) for Congenital Disorders and conditions arising out of or resulting therefrom

 

(7) Charges incurred for telephone consultations except Telemedicine consultations

 

(8) Charges incurred for failure to keep a scheduled appointment

 

(9) Charges incurred for Surgeries, Treatment or supplies which are Investigational, Experimental and for research purposes

 

(10) Charges incurred related to genetic medicine, genetic testing, surveillance testing and/or wellness screening procedures for

genetically predisposed conditions indicated by genetic medicine or genetic testing, including, but not limited to amniocentesis, genetic screening, risk assessment, preventive and prophylactic surgeries recommended by genetic testing, and/or any procedures used to determine genetic pre-disposition, provide genetic counseling, or administration of gene therapy

 

(11) Charges incurred for testing that attempts to measure aspects of an Insured Person’s mental ability, intelligence, aptitude, personality and stress management. Such testing may include but is not limited to psychometric, behavioral and educational testing

 

(12) Charges incurred for Educational or Rehabilitative Care that specifically relates to training or retraining an Insured Person to function in a normal or near-normal manner. Such care may include but is not limited to job or vocational training, counseling, occupational therapy and speech therapy

 

(13) Charges for weight modification or any Inpatient, Outpatient, Surgical or other Treatment of obesity (including without limitation morbid obesity), including without limitation wiring of the teeth and all forms or procedures of bariatric Surgery by whatever name called, or reversal thereof, including without limitation intestinal bypass, gastric bypass, gastric banding, vertical banded gastroplasty, biliopancreatic diversion, duodenal switch, or stomach reduction or stapling

 

(14) Charges for modification of the physical body in order to change or improve or attempt to change or improve the physical appearance or psychological, mental or emotional well-being of the Insured Person (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof)

 

(15) Charges or Treatment for cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and follows a Surgery which was covered under this insurance

 

(16) elective Surgery or Treatment of any kind

 

(17) Charges incurred for any Treatment or supply that either promotes or prevents or attempts to promote or prevent conception, insemination (natural or otherwise) or birth, including but not limited to: artificial insemination; oral contraceptives; Treatment for infertility or impotency; vasectomy; reversal of vasectomy; sterilization; reversal of sterilization; surrogacy or abortion

 

(18) Charges incurred for any Treatment or supply that either promotes, enhances or corrects or attempts to promote, enhance or correct impotency or sexual dysfunction

 

(19) any Illness or Injury sustained while taking part in, practicing or training for: Amateur Athletics; Professional Athletics; or athletic activities that are sponsored by any Governing Body or Authority including the National Collegiate Athletic Association, any other collegiate sanctioning or Governing Body or the International Olympic Committee

 

(20) any Illness or Injury sustained while taking part in activities designated as Adventure Sports, which are limited to the following: abseiling; BMX; bobsledding; bungee jumping; canyoning; caving; hot air ballooning; jungle zip lining; parachuting; paragliding; parascending; rappelling; skydiving; spelunking; wildlife safaris; and windsurfing

 

 (21) any Illness or Injury sustained while taking part in activities designated as Extreme Sports, which include but are in no way limited to the following (and include any combination or derivative of the following): BASE jumping; cave diving; cliff diving; downhill mountain biking and racing; extreme skiing; freediving; free flying; free running; free skiing; freestyle scootering; gliding; heli-skiing; ice canoeing; ice climbing; kitesurfing; mixed martial arts; motocross; motorcycle racing; motor rally; mountaineering above elevation of 4500 meters from ground level; parkour; piloting a commercial or non-commercial aircraft; powerbocking; scuba diving or sub aqua pursuits below a depth of 50 meters; snowmobile racing; truck racing; whitewater kayaking or whitewater rafting Class VI and higher difficulty; and wingsuit flying

 

(22) any Illness or Injury sustained while taking part in snow skiing, snowboarding or snowmobiling where the Insured Person is in violation of applicable laws, rules or regulations of a ski resort, out of bounds or in unmarked or unpatrolled areas

 

(23) any Illness or Injury sustained while taking part in backcountry skiing

 

(24) any Illness or Injury sustained while taking part in skiing off-piste

 

(25) any Illness or Injury sustained while taking part in Collision Sports

 

(26) any Illness or Injury sustained while taking part in athletic or recreational activities where the Insured Person is not physically or medically fit or does not hold the necessary qualifications to engage in said activities

 

(27) any Illness or Injury sustained while participating in any sporting, recreational or adventure activity where such activity is undertaken against the advice or direction of any local authority or any qualified instructor or contrary to the rules, recommendations and procedures of a recognized Governing Body for the sport or activity

 

(28) any Illness or Injury sustained while participating in any activity where such activity is undertaken in disregard of or against the recommendations, Treatment programs, or medical advice of a Physician or other healthcare provider

(29) any Injury or Illness sustained as a result of being under the influence of or due wholly or partly to the effects of alcohol, liquor, intoxicating substance, narcotics or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician but not for the Treatment of Substance Abuse

 

(30) any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs in excess of the applicable blood/alcohol legal limit, other than drugs taken in accordance with Treatment prescribed and directed by a Physician. For purposes of this exclusion, “vehicle” shall include motorized devices regardless of whether or not a driver or operator license is required (including watercraft and aircraft) and non-motorized bicycles and scooters for which no permit or license is required

 

(31) any willfully Self-inflicted Injury or Illness

 

(32) any sexually transmitted or venereal disease

 

(33) any testing for the following when not Medically Necessary: HIV, seropositivity to the AIDS virus, AIDS-related Illnesses, ARC Syndrome, AIDS

 

(34) any Illness or Injury resulting from or occurring during the commission of a violation of law by the Insured Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations

 

(35) any Substance Abuse

 

(36) biofeedback, acupuncture, music, occupational, recreational, sleep, speech, or vocational therapy

 

(37) orthoptics, visual therapy or visual eye training

 

(38) any non-surgical Illness or Treatment of the feet, including without limitation: orthopedic shoes; orthopedic prescription devices to be attached to or placed in shoes; Treatment of weak, strained, flat, unstable or unbalanced feet; metatarsalgia, bone spurs, hammer toes or bunions; and any Treatment or supplies for corns, calluses or toenails

 

(39) hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician

 

(40) any sleep disorder, including without limitation sleep apnea

 

(41) any exercise and/or fitness program or equipment, whether or not prescribed or recommended by a Physician

 

(42) any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s)

 

(43) any organ or tissue or other transplant or related services, Treatment or supplies

 

(44) any artificial or mechanical devices designed to replace human organs temporarily or permanently after termination of Inpatient

status

 

(45) any efforts to keep a donor alive for a transplant procedure

 

(46) any Illness or Injury incurred in the Destination Country 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 the Insured Person’s entry into the Destination Country, any of the following were issued regarding the Destination Country

(a) the World Health Organization had issued an Emergency Travel Advisory

 (b) the United States Centers for Disease Control & Prevention had issued a Warning Level 3 (avoid nonessential travel)

(c) a similar governmental agency of the Insured Person’s Country of Residence had published, communicated or issued a Travel Warning or Emergency Travel Advisory restriction or official declaration informing the public about such health issues before the Insured Person traveled to the Destination Country

 

(47) Charges incurred for eyeglasses, contact lenses, hearing aids or hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason

 

(48) Charges incurred for eye Surgery, such as but not limited to radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness, or astigmatism

 

(49) Charges incurred for Treatment or supplies for temporomandibular joint (TMJ) including but not limited to TMJ syndrome, craniomandibular syndrome, chronic TMJ pain, orthognathic Surgery, Le-Fort Surgery or splints

 

(50) Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance

 

(51) Charges incurred while in the Insured Person’s Country of Residence or as otherwise expressly provided for hereunder

 

(52) Except as otherwise expressly provided for in this insurance, Charges or expenses incurred for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; drugs or medicines not approved by the U.S. Food and Drug Administration or which are considered “off-label” drug use; and for drugs or medicines not prescribed by a Physician

(53) Charges incurred for Treatment or services provided in the home

 

(54) Charges incurred for prosthetics or orthotics

 

(55) any infection of the urinary tract (including, without limitation, infection of the kidney, ureter, bladder, prostate or urethra) and any complication, medical condition or other Illness directly or indirectly arising therefrom, that occurs within ninety (90) days of the Effective Date of this Insurance and that requires Treatment of the Insured Person in a Hospital as an Inpatient

 

(56) Charges incurred for massage therapy

 

(57) Charges for Treatment of an Illness or Injury for which payment is made or available through a workers' compensation law or a similar law

 

(58) Charges incurred for Dental Treatment, except as specifically provided for hereunder

 

ACUTE ONSET OF PRE-EXISTING CONDITIONS

Subject to the applicable Deductible and Coinsurance and the various limits and sub-limits set forth in the BENEFIT SUMMARY, and the Terms of this insurance, including without limitation the CONDITIONS AND RESTRICTIONS subparagraph below, and in the event the Insured Person suffers or experiences an Acute Onset of a Pre-existing Condition during the Period of Coverage for which immediate Treatment is essential and necessary to stabilize the Pre-existing Condition, the Insured Person will be reimbursed up to the amount shown in the BENEFIT SUMMARY for Eligible Medical Expenses incurred during the Period of Coverage with respect to the Acute Onset of the Pre-existing Condition.

Acute Onset of Pre-existing Conditions


Insured Person must be under 70 years of age

Refer to the ACUTE ONSET OF PRE-EXISTING CONDITIONS provision for further details and requirements

Maximum Limit: $25,000


or

Maximum Limit: $50,000

or

Maximum Limit: $100,000

Emergency Medical Evacuation

Arises or results directly from a covered Acute Onset of a Pre-existing Condition

Insured Person must be under 70 years of age

Maximum Limit: $25,000


or

Maximum Limit: $50,000

or

Maximum Limit: $100,000

CONDITIONS AND RESTRICTIONS

To be eligible for the foregoing limited coverage and benefits for an Acute Onset of a Pre-existing Condition, the Insured Person must be in compliance with all Terms of this insurance. The Company will provide such coverage and benefits only when all of the following conditions and restrictions have been met. At the time of the Acute Onset of the Pre-existing Condition:

(a) Treatment must be obtained within twenty-four (24) hours of the sudden and Unexpected outbreak or reoccurrence

(b) the Insured Person must be under seventy (70) years of age

(c) the Insured Person must not be traveling against or in disregard of the recommendations, established Treatment programs, or medical advice of a Physician or other healthcare provider

(d) the Insured Person must not be traveling with the intent or purpose to seek or obtain Treatment for the Pre-existing Condition

(e) the Insured Person must not be traveling during a period of time when the Insured Person is preparing or waiting for, involved in, or undertaking a new, changed or modified Treatment program with respect to the Pre-existing Condition, and is not traveling subsequent to any such new, changed or modified Treatment program having been advised or recommended

(f) the Pre-existing Condition must have been stabilized for at least thirty (30) days prior to the Effective Date without change in Treatment

(g) the Insured Person must be traveling outside their Country of Residence.

Pre-existing Condition

Any Injury, Illness, sickness, disease, or other physical, medical, Mental or Nervous Disorder, condition or ailment that, with reasonable medical certainty, existed at the time of Application or at any time during the three (3) years prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all subsequent, chronic or recurring complications or consequences related thereto or resulting or arising therefrom.

Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance.

Sudden and Unexpected Reoccurrence of a Pre-existing Condition

A sudden and unexpected outbreak or reoccurrence of a Pre-existing Condition is a condition:

(a) that 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 medical care

(b) that occurs after the Effective Date

(c) for which Treatment must be obtained within twenty-four (24) hours of the sudden and unexpected outbreak or reoccurrence.

A Pre-existing Condition is not a Sudden and Unexpected Reoccurrence of a Pre-existing Condition where:

(a) the Pre-existing Condition is chronic, congenital or a condition that gradually becomes worse over time

(b) medical care, drugs or Treatments were received, expected, scheduled, or required thirty (30) days prior to the Effective Date.

You can use the First Health Network to search for Doctors/providers.

                                                                                RENEWAL

RENEWAL; AMENDMENTS: Subject to the Terms of the Termination of Master Policy and TERMINATION OF COVERAGE FOR INSURED PERSONS subparagraphs of the CONDITIONS AND GENERAL PROVISIONS, an Insured Person can request coverage under this insurance plan to be extended a minimum of five (5) days for up to a three hundred sixty-five (365) day period until reaching a maximum of twenty-four (24) continuous months in accordance with and subject to the Terms of the plan then in effect (including the Terms of the then applicable Master Policy) and so long as extension Premium

The Company’s commitment and the Insured Person’s ability to request extension is also subject to termination upon thirty (30) days written notice to the other party prior to the expiration date of the then existing Period of Coverage. The Company reserves the right in its sole discretion to make changes, additions, and/or deletions to the Terms of the Master Policy, this Certificate, extensions or replacements of either, and/or to the insurance plan (including the issuance of Riders to effectuate same) at any time or from time to time after the Effective Date of Coverage of this Certificate, upon no less than ninety (90) days prior written notice to the Assured and the Insured Person (Notice of Amendment). The Notice of Amendment shall include a complete description of the changes, additions, and/or deletions to be made, the Effective Date thereof (the Change Date), and notice of the Insured Person’s cancellation rights and shall be sent first class mail, postage prepaid, to the last known residence or mailing address of the Insured Person. Upon issuance of the Notice of Amendment, the Assured and/or the Insured Person shall have the right to request cancellation of this Certificate, at any time prior to the Change Date; provided, however that cancellation under this provision shall be at the option of the Insured Person and coverage under this insurance shall terminate with effect from the cancellation date specified by the Insured Person (subject to the Terms of the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF COVERAGE FOR INSURED PERSONS provision). If the Insured Person does not elect to cancel this Certificate in accordance with the foregoing, the changes, additions, and/or deletions as made by the Company and specified in said Notice of Amendment shall take effect as of the Change Date specified in the Company’s Notice, and this insurance shall thereafter continue in effect in accordance with its Terms, as so amended and modified.

                                                                CANCELLATION

CANCELLATION BY INSURED PERSON: The Insured Person shall have three (3) days from the Initial Effective Date of Coverage (the “Review Period”) to review the benefits, conditions, limitations, exclusions and all other Terms of the Master Policy as evidenced and outlined by this Certificate. If not completely satisfied, the Insured Person may request cancellation of this insurance retroactive to the Initial Effective Date of Coverage by sending a written request to the Company by email, mail or fax and received by the Company within the Review Period, thereby qualifying to receive a full refund of Premium paid. Upon effectuation of such cancellation and refund, neither the Company nor the Insured Person shall have any further rights, liabilities or obligations under this insurance. After the Review Period, the following conditions apply if the Insured Person wishes to cancel this insurance:

(a) If any claims have been filed with the Company, the Premium is fully earned and is non-refundable.

(b) If no claims have been filed with the Company:

(i) a cancellation fee of fifty dollars ($50.00 USD) will be charged; and

(ii) only Premium covering time periods after cancellation are refundable; and

(iii) only full month Premiums are refundable.

CLAIM

CLAIMS NOTIFICATION: All claims and related claim information should be filed with the Company through the Plan Administrator at the contact information below, or online at www.imglobal.com/member as soon as possible:

International Medical Group

 Attn: Claims Department

PO Box 88500

 Indianapolis, IN 46208-0500

USA

Proof of Claim: When the Company receives notice of a claim for benefits under this insurance from or on behalf of an Insured Person, it will provide the Insured Person with a Claim Form & Authorization for filing Proof of Claim.

(a) All of the following items must be submitted by or on behalf of the Insured Person to be considered a complete Proof of Claim eligible for consideration of coverage under this insurance:

 (i) a duly completed, timely submitted, and signed claim form and authorization for release of information

 (ii) all original itemized bills and statements of services rendered from Physicians, Hospitals, and other healthcare or medical service providers involved with respect to the claim

(iii) all original receipts for any costs, fees or expenses that have been incurred or paid by or on behalf of the Insured Person with respect to the claim, including without limitation all original receipts for any cash and/or credit card payments. The provider of service’s full name, address, telephone number (including area/country code), date of service, description of services (applicable procedure codes), and diagnosis code must be included on the receipts.

(b) The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have one hundred eighty (180) days from the date a claim is incurred to submit a complete Proof of Claim. The Company at its option may pend resolution and adjudication of submitted claims and/or may deny coverage due to either of the following:

(i) an incomplete Proof of Claim

 (ii) failure to submit a Proof of Claim

The Company at its option may waive the requirements regarding submission of a new claim form for subsequent claims incurred by an Insured Person relating to a continuing Illness, Injury or other medical condition for which a properly completed and signed Claim Form & Authorization has previously been submitted and received.

 APPEALING A CLAIM: In the event the Company denies all or part of a claim, the Insured Person shall have sixty (60) days from the date that the notice of denial was mailed to the Insured Person's last known residence or mailing address within which to appeal the determination. The Insured Person must file an appeal prior to bringing any legal action under the contract of insurance. The Insured Person should submit a written request for an appeal along with comments, all relevant, pertinent or related documents, medical records, and other information relating to the claim.

The appeal must be sent to:

International Medical Group

Attn: Benefit Review 2960 N. Meridian Street

Indianapolis, IN 46208

USA

The Company’s review will take into account all comments, documents, records, and other information submitted by the Insured Person relating to the claim, without regard to whether such information was submitted or considered in the initial claim determination. Upon receipt of a written appeal, the Company shall have an opportunity for further reasonable investigation and/or review as set forth in the CONDITIONS AND GENERAL PROVISIONS, EXPLANATION OR VERIFICATION OF BENEFITS provision, and will respond in writing as soon as reasonably practicable, and in any event within ninety (90) days from receipt thereof.

SUBROGATION CLAUSE: The Insured Person shall undertake to pursue in his/her own name and stead, and to fully cooperate with the Company in the pursuit and prosecution of, any and all valid claims that the Insured Person may have against any third party who may be liable or responsible for any loss or damage arising out of any act, omission or occurrence which results or may result in a loss payment, provision of benefits, or coverage of claim by the Company under this insurance, and to fully account to the Company for any amounts recovered or recoverable in connection therewith, on the basis that the Company shall be reimbursed and entitled to recover first in full for any sums paid or to be paid by it before the Insured Person shares in any amount so recovered.

The Insured Person further agrees and understands that the Company requires the Insured Person to complete a subrogation questionnaire, sign an acknowledgment of the Company's subrogation rights and sign an agreement before the Company considers paying, or continues to pay, any claims. Should the Insured Person fail to so cooperate, account, or to prosecute any valid claims against any such third party or parties, and the Company thereupon or otherwise becomes liable or otherwise obligated to make payment under the Terms of this insurance, then the Company shall be fully subrogated to all rights and interests of the Insured Person with respect thereto and may prosecute such claims in its own name as subrogee.

The Insured Person’s submission of Proof of Claim or acceptance of coverage or benefits under this insurance shall be deemed to constitute an authorization, consent and assignment of such subrogation rights by the Insured Person to the Company. The Insured Person agrees the Company has a secured proprietary interest in any settlement proceeds the Insured Person receives or may be entitled to receive.

The Insured Person understands and agrees the Company is entitled to a constructive trust interest in the proceeds of any settlement or recovery. The Insured Person agrees to include the Company as a co-payee on any settlement check or check from any third party or insurer. The Insured Person agrees he/she will not release any party or their insured without prior written approval from the Company, and will take no action which prejudices the Company's rights.

The Insured Person is obligated to inform their legal representative of the Company’s rights and lien and to make no distributions from any settlement or judgment which will in any way result in the Company receiving less than the full amount of its lien without the written approval of the Company. Any amount recovered by the Company in accordance with the foregoing shall first be used to pay in full the costs and expenses of collection incurred by the Company, including reasonable attorneys’ fees, and for reimbursement to the Company for any amount that it may have paid or become liable to pay under this insurance. Any remaining amounts recovered shall be paid to the Insured Person or other persons lawfully entitled thereto, as applicable. In the event that the Insured Person receives any form or type of settlement and either fails or refuses to abide by the Terms of this insurance contract, in addition to any other remedies the Company may have, the Company retains a right of equitable offset against future claims.

OTHER INSURANCE: The Company shall not be liable or obligated to provide any coverage or benefits or to pay or reimburse any claim under this insurance if there is any other insurance, membership benefit, workers’ or workplace compensation coverage program or other government program, reimbursement or indemnification coverage, right of contribution, recoupment or recovery, contract, or any other third-party obligation or liability for provision of benefits (“Other Coverage”) which would, or would but for the existence of this insurance, be available or obligated to provide such benefit or to pay or reimburse or provide indemnity for such claim, except in respect of any excess beyond the amount payable or provided under such Other Coverage had this insurance not been effected. Notwithstanding the foregoing, the Company shall not be liable or obligated to provide any benefit or to pay or reimburse any claim for any Insured Person in respect to Treatment or supplies furnished by any program or agency funded by any government or governmental authority

COOPERATION: The Insured Person and his/her Physicians, Hospitals and other healthcare and medical service providers and suppliers shall undertake to cooperate fully with the Company and the Plan Administrator in reviewing, investigating, adjudicating, considering an appeal of, and/or administering any claim for benefits under this insurance, including granting full right of access to all relevant, pertinent or related records, medical documentation, medical histories, reports, laboratory or test results, x-rays, and all other available evidence relating to or affecting the review, investigation, adjudication or administration of the claim. The Company at its own expense shall have the right and opportunity to examine all evidence related to a claim when and as often as it may reasonably require during the pendency of a claim hereunder. The Company at its option may suspend or pend adjudication of a claim and/or may deny benefits and/or coverage for a claim when any of the following has occurred:

(a) a refusal to so cooperate

 (b) an unreasonable delay in such cooperation

(c) any other act or omission on the part of the Insured Person and/or his/her healthcare providers which hinders, delays, impairs or otherwise prejudices the performance of the Company’s obligations under this insurance.

CLAIM SETTLEMENT: Eligible and covered claims for Eligible Medical Expenses or other benefits under this insurance that have previously been paid by or on behalf of the Insured Person at the time of the Company’s favorable adjudication thereof will be reimbursed by the Company directly to the Insured Person, by check, at his/her last known residence or mailing address. While this insurance is in effect, in order to effectuate proper administration, the Insured Person shall undertake to promptly notify the Company of any change in such addresses. Eligible and covered claims for Eligible Medical Expenses or other benefits under this insurance that have not been paid by or on behalf of the Insured Person at the time of adjudication will be paid by the Company by check or electronic funds transfer to the Insured Person at his/her last known residence or mailing address, or, at the sole option and discretion of the Company (but without obligation to do so), and as an accommodation to the Insured Person, directly to the provider(s), as applicable. All claim settlements, payments and reimbursements are subject to the insurance plan shown in the Declaration and all other Terms of this insurance. No healthcare or medical service provider or supplier, or any other third-party, shall have any direct or indirect interest, claim or right of action against the Company under this Certificate, the Declaration or the Master Policy, whether by purported assignment of benefits, subrogation of interests or otherwise, unless first expressly agreed and consented to in writing by the Company, and notwithstanding the Company’s exercise or failure to exercise any option or discretion under this provision regarding the method of claim payment. No such provider, supplier or other third-party is intended to have or shall have any rights as a third-party beneficiary under this Certificate, the Declaration, or the Master Policy.

FRAUDULENT CLAIMS: A person who knowingly and with intent to defraud the Company files a statement of claim containing any false, incomplete, or misleading information commits a felony. If any claim or request for benefits under this insurance shall knowingly be in any respect false, incomplete, misleading, concealing, fraudulent or deceitful, or if the nsured Person or anyone acting for or on his/her behalf under this insurance knowingly uses any false, incomplete, misleading, concealing, fraudulent or deceitful statements regarding the Insured Person, the insurance contract and all coverage thereunder may be cancelled, voided, rescinded and terminated by the Company in its sole and absolute discretion, and the Company shall have no obligation or liability for any such benefits, coverage or claims.

ARBITRATION: With the exception of Florida residents’ option to refer to arbitration, no claim for benefits for which liability, eligibility, or coverage under this insurance has been denied in whole or in part by the Company nor any other dispute or controversy arising under or related to this insurance shall be arbitrable or subject to arbitration under any circumstances or for any reason.

PATIENT ADVOCACY: Neither the Company nor the Plan Administrator shall have any right, obligation, or authority of any kind to ultimately select Physicians, Hospitals, or other healthcare or health service providers for the Insured Person or to make any medical Treatment decisions for or on behalf of the Insured Person, and all such decisions shall be made solely and exclusively by the Insured Person and/or his/her guardians, Relatives, treating Physicians and other healthcare providers. Subject to the foregoing, the Company may determine that a particular claim, benefit, Treatment or diagnosis occurring under or relating to this insurance may be placed under the Company’s “Patient Advocacy” program to ensure that Medically Necessary Treatment and supplies are provided in the most cost-effective manner. In the event the Company determines that a claim, benefit, Treatment, or diagnosis meets the Company’s Patient Advocacy program guidelines, the Company will notify the Insured Person as soon as reasonably practicable, and a Patient Advocate will be assigned to the Insured Person. Thereafter, the Company’s Patient Advocate may make evaluations and/or recommendations of Treatment settings, procedures and/or supplies that may be more cost effective for the Company and/or the Insured Person. Such recommendations will be made with input from the Insured Person and/or the Insured Person's guardians, Relatives, treating Physicians and/or other healthcare providers, and will be made only when it can be reasonably demonstrated that the Medically Necessary Treatment and/or supplies can be provided in a more cost-effective manner to the Company and/or the Insured Person. The Company will use its best efforts to evaluate and recommend Treatment settings and/or procedures and/or supplies that can reasonably be expected to result in the same or better care of the Insured Person. The Insured Person is under no obligation to accept or follow any of the Company’s recommendations. However, if the Insured Person accepts and follows any of the Company's recommendations, the Insured Person agrees to hold the Company and the Company’s agents and representatives, including the Patient Advocate, harmless from same, and the Company shall not be held liable or otherwise responsible for any Treatment or supply provided to the Insured Person except for the payment of claims and benefits eligible for coverage under the Terms of this insurance. After the Insured Person has been notified that the claim, Treatment, benefit or diagnosis meets the Company’s Patient Advocacy program guidelines, the Company reserves the right, at its option and in its sole discretion without liability

(a) to make payment for Treatment and/or supplies which, although not expressly covered under this insurance, may be beneficial to the Insured Person and cost effective to the Company; and/or

(b) to deny coverage and/or benefits for any Charges, including Eligible Medical Expenses otherwise eligible for coverage but for the Terms of this provision, which exceed the amount the Company would have covered had the Insured Person accepted and followed the recommendations of the Patient Advocacy program.