Global Mission Medical Insurance - Gold Plus
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:
- 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; and
- pay the required Premium on or before the Effective Date of Coverage; and
- receive written acceptance of his/her Application or renewal from the Company; and
- be at least fourteen (14) days old but not yet seventy-five (75) years old; and
- not be Pregnant, Hospitalized or Disabled on the Initial Effective Date; and
- not be HIV+ on the Initial Effective Date; and
- if a United States citizen, must be residing outside of the USA as of the Effective Date (or renewal date) and plan to reside outside of the USA for at least six (6) of the next twelve (12) months thereafter; or
- if not a United States citizen: (a) must reside outside the USA at time of Application (or renewal); or (b) must plan to reside outside of the USA continuously for at least six (6) months during the Period of Coverage with required departure from the USA not more than thirty (30) days after the Initial Effective Date or renewal Effective Date; or (c) if located inside the USA at the time of Application (or renewal), must not be eligible for any other medical insurance plan which is available to individuals similarly situated and located in the USA and must provide the Company an Affidavit of Eligibility
Subject to the Terms of this insurance and the insurance plan shown in the Declaration, the following insurance plans are available to the Insured Person and offer the following benefits and coverage arising out of Injury or Illness incurred while the insurance plan shown in he Declaration is in effect:
|LIMIT/OTHER||LIMIT/AMOUNT FOR ELIGIBLE MEDICAL EXPENSES|
|Area of Coverage||Area 2: Worldwide Excluding USA, Canada, China, Hong Kong, Japan, Macau, Singapore and Taiwan
Area 3: Worldwide as indicated on Declaration. If the Area is blank on the Declaration, the Area of Coverage is Worldwide.
|Maximum Limit per lifetime||Per Insured Person, as indicated on the Declaration Page.|
|Deductible||Per Insured Person and as indicated on the Declaration. An additional Deductible of $250 will be applied for each Emergency Room visit for Treatment of an Illness which does not result in Inpatient status.
US PPO Provider: 100% of Deductible.
US Non PPO Provider: 100% of Deductible
Non US Provider: Lesser of 50% of Deductible or $2,500.
US Medical Concierge Provider: Lesser of 50% of Deductible or $2 500.
Inpatient Emergency Treatment
US PPO Provider: 100% of Deductible.
US Non PPO Provider: 100% of Deductible.
Non US Provider: Lesser of 50% of Deductible or $2 500
Inpatient Non Emergency Treatment
US PPO Provider: 100% of Deductible.
US Non PPO Provider: 100% of Deductible.
Non US Provider: Lesser of 50% of Deductible or $2,500
US Medical Concierge Provider: Lesser of 50% of Deductible or $2 500
|Deductible Carry Forward||If the eductible has not been met during the Period of Coverage then Expenses incurred during the last 30 days of the Period of Coverage will be applied toward satisfaction of the Deductible for the next Period of Coverage|
|Coinsurance||Treatment received outside the US: Plan pays 100%, and Insured pays 0% of Eligible Medical Expenses up to Maximum Limit.
Treatment received within the US: In the PPO Network or Medical Concierge Provider: he plan pays 100 and Insured pays 0% of ligible Medical Expenses up to Maximum Limit.
Outside the PPO Network: he lan pays 80% and Insured Person pays 20% of ligible Medical Expenses up to US$5 000, then Plan pays 100% up to Maximum Limit
The following benefits are subject to the Deductible and Coinsurance, as described above and cannot exceed the Maximum Limit. When the Eligible Medical Expense criteria are met, the benefits offered under the insurance plan shown in the Declaration shall be as follows:
|CHARGES FOR:||MAXIMUM LIMITS PER PERIOD OF COVERAGE OR IF INDICATED, PE LIFETIME|
|Eligible Medical Expenses||Usual, Reasonable and Customary.|
|Emergency Dental Treatment||$100 Maximum Limit for necessary Treatment of Unexpected pain to sound natural teeth or due to an Accident|
|Hospital Room & Board||Treatment in the United States: Up to the average semi private room rate, including nursing service
Treatment outside of the United States: verage private room rate, including nursing service, up to a maximum of 150% of the average semi private room rate
|Intensive Care Unit||Usual, Reasonable and Customary.|
|Mental or Nervous Disorders||$50,000 Maximum Limit per lifetime (after 12 months of continuous coverage); and 10,000 Maximum Limit per Period of Coverage.|
|Pre Existing Conditions||$50,000 Maximum Limit per lifetime (after 24 months of continuous coverage); and $5,000 Maximum Limit per Period of Coverage.|
|Physical Therapy||$50 aximum Limit per visit, and limited to one (1) visit per day.|
|Complementary Medical Service||Maximum Limits Per Insured Person:
Magnetic Therapy: $75
Herbal Therapy: $50
Massage Therapy: $150
Aroma Therapy: $50
Vitamin Therapy: $100
|Bereavement Counseling||$300 Maximum Limit and 15 maximum visits per family. Services must be received prior to or within 6 months after the Insured's death|
|Emergency Reunion||$10,000 Maximum Limit per lifetime, and Maximum Limit of 15 days for reasonable and necessary travel costs, meals (maximum of $25 per day), transportation and accommodation expenses. Must be approved in advance and coordinated by the Company.|
|Local Ambulance Expense||Usual, Reasonable and Customary per Covered Illness or Injury resulting in Hospitalization|
|Assistant Surgeon||Plan pays 20% of the Usual, Reasonable and Customary charge of the primary surgeon.|
The following benefits are not subject to a Deductible or Coinsurance, but cannot exceed the Maximum Limit. The benefits offered under the insurance plan shown in the Declaration shall be as follows:
|BENEFIT||MAXIMUM LIMITS PER PERIOD OF COVERAGE OR IF INDICATED, PER LIFETIME|
|Supplemental Accident Benefit||$300 of Eligible Medical Expenses following an Accident.|
|Wellness Expenses||Adult: $250 Maximum Limit per Period of Coverage (after 12 months of continuous coverage) for Insured Persons age 19 and over.
Child: $200 Maximum Limit per Period of Coverage after 12 months of continuous coverage through age 18
|Hospital Indemnity||Private Hospitals $400 per overnight and $4,000 Maximum Limit per Period of Coverage
Public Hospitals $500 per overnight and $5,000 Maximum Limit per Period of Coverage
when Other Coverage exists and Company is not obligated to pay any benefits.
|Emergency Medical Evacuation||Up to the Maximum Limit. Must be approved in advance and coordinated by the Company. Not subject to Deductible or Coinsurance.|
|Return of Mortal Remains||$25,000 Maximum Limit for return of the Insured Person's Mortal Remains or ashes to their Home Country. Must be approved in advance and coordinated by the Company. Not subject to Deductible or Coinsurance.|
|Transplant Expense||$1,000,000 Maximum Limit per Lifetime; $10,000 Maximum Limit per lifetime for associated organ procurement & harvesting costs; $5,000 Maximum Limit per ifetime for associated travel & lodging expenses. Maximum limit of one (1) covered transplant per Period of Coverage. Subject to special transplant Pre certification provisions and only when Treatment is provided within the Company's approved independent Managed Transplant System Network. Covered Transplants are: cornea, heart, heart/lung, lung, kidney, kidney/pancreas, liver or allogeneic or autologous bone marrow.|
|Pre Certification||Transplants: No coverage if Pre certification provisions are not met. All other Treatments and supplies: 50% reduction of Eligible Medical Expenses if Pre certification provisions are not met.|
|Second Surgical Opinion||50% reduction of Eligible Medical Expenses for failure to obtain a Second Surgical Opinion when required by the Company.|
|Area 2 Out of Area Treatment||Maximum Limit of 30 days per Insured Person per Period of Coverage for Accident or Emergency Treatment only. Treatment in the US must be received from a Physician, Hospital or other healthcare provider within the Preferred Provider Network.|
|Continuous coverage means consecutive, unbroken coverage under the Global Medical Insurance plan.|
All charges, costs, expenses and/or claims (collectively “Charges”) 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:
War; Military Action
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 any of the following acts or events (collectively, “Occurrences”):
- war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war;
- mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power;
- 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;
- martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege; and
- 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).
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 such claim, Charges, Illness, Injury or other consequence happened independently of the existence of such abnormal conditions and/or Occurrences.
The Company shall not be liable for and will not provide coverage or benefits for any claim or charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with any act of Terrorism. Further, the Company shall not be liable for and will not provide any coverage or benefits for any claim, charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with the following:
- the Insured Person’s active and voluntary planning or coordination of or participation in any act of Terrorism; and/or
- any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning was issued or in effect on or within six (6) months prior to the Insured Person’s date of arrival in said location, post, area, territory or country; and/or
- any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning becomes effective or is in effect on or after the Insured Person’s date of arrival in said location, post, area, territory or country, and the Insured Person unreasonably fails or refuses to heed such warning and thereafter remains in said location, post, area, territory or country.
- (i) For medical conditions existing at the time of Application which are fully disclosed on the Application and are not excluded or restricted through a Rider attached to this Certificate and for medical conditions which existed but that were unknown at the time of Application, charges resulting directly or indirectly from or relating to any such Preexisting Condition are excluded from coverage under this insurance until the Insured Person has maintained coverage under this insurance plan continuously for at least twenty-four (24) months, and thereafter such Charges are limited in coverage as provided in the SCHEDULE OF BENEFITS/LIMITS section; and
- (ii) Any expenses incurred, obtained, or received by an Insured Person for any Non-Disclosed conditions will be excluded under this insurance; and
Illness or Surgery Within 180 Days
Charges for Treatment of the following Illnesses or Surgeries which manifest themselves and/or involve procedures which take place and/or are recommended during the first one-hundred eighty (180) days of coverage under this insurance plan, beginning on the Initial Effective Date: acne, asthma, allergies, any condition of the breast, any condition of the prostate, tonsillectomy, adenoidectomy, hemorrhoids or hemorrhoidectomy, disorders of the reproductive system, diverticulitis, hysterectomy, hernia, intervertebral disc disease, gall bladder disease or gall stones and kidney stones. Note: Coverage and/or benefits for these Illnesses or Surgeries (or for similar or different Illnesses or Surgeries) may be separately or further limited and/or excluded under the Pre-existing Conditions exclusion and definition; and
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; and
Charges for any Treatment or supplies that are:
- not incurred, obtained or received by an Insured Person during the Period of Coverage; and/or
- not presented to the Company for payment by way of a complete Proof of Claim within ninety (90) days of the date such Charges are incurred; and/or
- not administered or ordered by a Physician; and/or
- not Medically Necessary; and/or
- provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable; and/or
- in excess of Usual, Reasonable, and Customary; and/or
- incurred by an Insured Person who was HIV + on or before the Effective Date of this insurance 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; 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; and/or
- provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician; and/or
- performed or provided by a Relative of the Insured Person; and/or
- not expressly included as Eligible Medical Expenses; and/or
- provided by a person who resides or has resided with the Insured Person or in the Insured Person's home; and/or
- 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; and
- for Congenital Disorders and conditions arising out of or resulting there from; and
Charges incurred for telephone consultations except those incurred using Teladoc or other 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; and
Charges incurred due to a failure to keep a scheduled appointment; and
Charges incurred for Surgeries or Treatment or supplies which are:
- Investigational, Experimental, or for research purposes, and/or
- 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; and
Charges incurred for psychometric, behavioral, and educational testing; financial, relationship, and/or career counseling, services or assessments; or while confined primarily to receive Custodial Care, Educational or Rehabilitative Care; and
Charges incurred for any Surgery, Treatment or supplies relating to, arising from or in connection with, for, or as a result of:
- 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; and/or
- 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); and/or
- elective Surgery or Treatment of any kind; and/or
- 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; and/or
- any Illness or Injury sustained while taking part in: Amateur Athletics, Professional Athletics, or other athletic activity that is sponsored or sanctioned by the National Collegiate Athletic Association (and/or any other collegiate sanctioning or governing body), or the International Olympic Committee, and Adventure Sports and activities not expressly covered hereunder or approved in writing by the Company, including, without limitation Collision Sports of any kind as well as the following (including any combination or derivative of the following): abseiling; athletic or sporting activities (except for activities that are non-Collision and engaged in by the Insured Person solely for recreational, entertainment or fitness purposes); aviation (except when travelling solely as a passenger in a commercial aircraft); BMX; BASE jumping; bobsledding; bungee jumping; canyoning; caving; hang gliding; heli-skiing; high diving; hot air ballooning; inline skating; jet skiing; jungle zip lining; kiteboarding; kayaking; luge; motocross (MOTO-X); mountain biking; mountaineering activities where specialized climbing equipment, ropes or guides are normally or reasonably should have been used; parachuting; paragliding; parascending; racing of any kind including without limitation by horse, motor, motorcycle, automobile, or any other motorized or non-motorized vehicle of any type or other means; rappelling; rock climbing; any rodeo activity; ski jumping; sky diving; snow skiing except for recreational downhill and/or cross country snow skiing (provided that there is no coverage for any Illness of Injury sustained while skiing in violation of applicable laws, rules or regulations; away from prepared and marked in-bound territories; and/or against the advice of the local ski school or local authoritative body); snowboarding; snowmobiling; spelunking; surfing; trekking; whitewater rafting; windsurfing; wildlife safaris; and any sub-aqua pursuits involving underwater breathing apparatus below a depth of 30 meters. Practice or training in preparation for any excluded activity which results in Illness or Injury will be considered as activity while taking part in such activity; and /or
- any Illness or Injury sustained while participating in any sporting, recreational or adventure activity where participation in such activity is being compensated; undertaken for hire, without any required licenses, certifications, or equipment; and/or against the advice or direction of any local authority or any qualified instructor or contrary to the rules, standards, recommendations, and procedures of a recognized governing body for the sport or activity; and/or
- 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; and/or
- 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; and/or
- any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs 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; and/or
- any willfully Self-inflicted Injury or Illness; and/or
- any sexually transmitted or venereal disease; and/or
- any testing for the following: HIV, seropositivity to the AIDS virus, AIDS related Illnesses, ARC Syndrome, AIDS; and/or
- 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; and/or
- any Substance Abuse; and/or
- biofeedback, recreational, sleep or music therapy; and/or
- orthoptics, visual therapy or visual eye training; and/or
- 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; except as otherwise expressly set forth; and/or
- hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician; and/or
- any sleep disorder, including without limitation sleep apnea; and/or
- any exercise and/or fitness program or equipment, whether or not prescribed or recommended by a Physician; and/or
- any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s); and/or
- any organ or tissue or other transplant or related services, Treatment or supplies, except as otherwise expressly set forth; and/or
- any artificial or mechanical devices designed to replace human organs temporarily or permanently after termination of Inpatient status; and/or
- any efforts to keep a donor alive for a transplant procedure, whether or not the transplant procedure is a Covered Transplant; and/or
- any transplant expenses incurred outside the Company’s approved independent Managed Transplant System Network; and/or
- any Covered Transplant in excess of one (1) during any twelve (12) month period of coverage under this insurance plan, except re-transplantation Charges if incurred during the initial Covered Transplant Hospitalization; and
- any Illness or Injury resulting from or sustained after entering the Host Country and as a result of epidemics, pandemics, public health emergencies, natural disasters, or other disease outbreak conditions that may affect a person’s health and about which the World Health Organization has issued an Emergency Travel Advisory, US Centers for Disease Control & Prevention has issued a warning Level 3 (avoid nonessential travel), or similar governmental agency of the Insured Person’s Country of residence had published, communicated or issued a Travel Warning restriction, or official declaration informing the public about such health issues before the Insured Person traveled to the Host Country; and
Charges incurred for any Treatment or supply that either promotes or prevents or attempts to promote or prevent conception or birth; including but not limited to: artificial insemination; oral contraceptives, Treatment for infertility or impotency; vasectomy or reversal of vasectomy; sterilization or reversal of sterilization; surrogacy or abortion; and
Charges incurred for any Treatment or supply that either promotes, enhances or corrects or attempts to promote, enhance or correct impotency or sexual dysfunction; and
Charges incurred for Dental Treatment, except for Emergency Dental Treatment necessary to repair or replace sound natural teeth lost or damaged in an Accident covered hereunder, or as necessary treatment of sudden, unexpected pain to sound natural teeth, and subject to the limits set forth in the Schedule of Benefits/Limits; and
Charges incurred for eyeglasses, contact lenses, hearing aids, hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason; and
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; and
Charges incurred for Treatment or supplies for temporomandibular joint TMJ syndrome, craniomandibular syndrome, chronic TMJ pain, orthognathic Surgery, Le-Fort Surgery or splints; and
Charges incurred by the Insured Person for the Treatment of his/her Newborns (or for supplies related thereto); and
Charges incurred for any immunizations and/or routine physical exams except as otherwise expressly provided for hereunder; and
Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance; and
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.
Acute Pre-Ex Coverage
$50,000 lifetime maximum; $5,000 per period of coverage after 24 months.
Acute Onset of Pre-existing Condition sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the effective date of the policy. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset.
Renewal of Coverage
Subject to the Terms of the TERMINATION OF MASTER POLICY, TERMINATION OF COVERAGE FOR INSURED PERSONS, and REINSTATEMENT OF COVERAGE FOR INSURED PERSONS sections, the Insured Person can request coverage under this insurance plan to be renewed from year to year 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 renewal Premium is paid when due and the Insured Person otherwise continues to meet the applicable eligibility requirements of the plan. The Company’s commitment and the Insured Person’s ability to renew 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, renewals or replacements of either, and/or to the Global Medical 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 thirty (30) 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 as set forth below, and shall be sent electronically or first class mail, postage pre-paid, 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 above, at any time prior to the Change Date; provided, however that cancellation under this section 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 provisions of the TERMINATION OF COVERAGE FOR INSURED PERSONS section. 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.
The Insured Person shall have fifteen (15) 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 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 Insured Person may request cancellation of the Declaration and this Certificate by giving the Company not less than sixty (60) days advance written request. Cancellation is at the sole option of the Company, except as provided in the RENEWAL; AMENDMENTS section, and the Company may request and/or require the Insured Person to execute a release of claims as a condition to and/or in consideration of granting such cancellation. If the Company grants cancellation, coverage for the Insured Person under this insurance shall terminate with effect from the cancellation date specified by the Company. The Company shall calculate the amount of Premium earned upon the Declaration and Certificate through the requested date of cancellation (Short Rate Earned Premium) in accordance with the Short Rate Cancellation Table in effect as of the date of the request for cancellation. If the Insured Person has paid more than the Short Rate Earned Premium, the Company shall refund the difference between the amount actually paid and the Short Rate Earned Premium. If the Insured Person has paid less than the Short Rate Earned Premium, the Insured Person shall remit to the Company the difference between the Short Rate Earned Premium and the amount actually paid as a condition to cancellation as of such requested date, or the cancellation date will be established retroactive to the date through which and for which Premiums have actually been paid.
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 Claimant’s Statement and Authorization Forms (“Claim Forms”) for filing Proof of Claim. 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 (“Proof of Claim”):
- a duly completed, timely submitted, and signed Claim Form and authorization for release of information; and
- all original itemized bills and statements of services rendered from all Physicians, Hospitals and other healthcare or medical service providers involved with respect to the claim; and
- 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 Insured Person and/or Physician, Hospital and other healthcare and medical service providers and supplier shall have ninety (90) days from the date a claim is incurred to submit a complete Proof of Claim, and the Company at its option may pend resolution and adjudication of submitted claims and/or may deny coverage: for Proofs of Claim submitted thereafter; or for incomplete Proofs of Claim; and/or for failure to submit a Proof of Claim; provided, however, that 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 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 a maximum of two mandatory appeal levels to appeal the denial under which there will be a review of the claim and the determination. Insured Persons 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, and shall have the opportunity to submit written comments, documents, records, and other information relating to the claim. 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. Insured Persons must file two (2) appeals of a claim denial prior to bringing any legal action under the contract of insurance. Upon receipt of a written appeal, the Company shall have an opportunity for further reasonable investigation and/or review as set forth in the Explanation or Verification of Benefits section, and will respond in writing as soon as reasonably practicable, and in any event within ninety (90) days from receipt thereof.
If Outpatient, Emergency Inpatient or Non-Emergency Inpatient Treatment or supplies eligible for coverage under this insurance are received directly from the Company’s approved list of independent PPO providers while the Insured Person is in the United States the Company will waive any and all Coinsurance applicable to such claims.
However, all claims for Treatment or supplies received in the United States from a non-PPO provider will remain subject to the applicable Deductible and Coinsurance, whether or not the Insured Person may be eligible for the foregoing special benefit relating to Treatment or supplies received from PPO providers.
The Company, through the Plan Administrator, endeavors to maintain a contractual arrangement with one or more independent Preferred Provider Organizations (PPO) that has established and maintains a network of U.S.-based Physicians, Hospitals and other healthcare and health service providers who are contracted separately and directly with the PPO and who may provide re-pricings, discounts or reduced charges for Treatment or supplies provided to the Insured Person. Neither the Company nor the Plan Administrator has any authority or control over the operations or business of the PPO, or over the operations or business of any provider within the independent PPO network. Neither the PPO nor provider within the PPO network nor any of their respective agents, employees or representatives has or shall have any power or authority whatsoever to act for or on behalf of the Company or the Plan Administrator in any respect, including without limitation no power or authority to: (i) approve Applications or enrollments for initial, renewal or reinstated coverage under this insurance plan or to accept Premium payments, (ii) accept risks for or on behalf of the Company, (iii) act for, speak for, or bind the Company or the Plan Administrator in any way, (iv) waive, alter or amend any of the Terms of the Master Policy or this Certificate or waive, release, compromise or settle any of the Company’s rights, remedies, or interests thereunder or hereunder, or (v) determine Precertification, eligibility for coverage, verification of benefits, or make any coverage, benefit or claim adjudications or decisions of any kind. It is not a requirement of this insurance that the Insured Person seek Treatment or supplies exclusively from a provider within the independent PPO network. However, the Insured Person’s use or non-use of the PPO network may affect the scope and extent of benefits available under this insurance, including without limitation any applicable benefit reduction, Deductible, Coinsurance and Extra Deductible, as set forth above. An Insured Person may contact the Company through the Plan Administrator and request a PPO Directory for the area where the Insured Person will be receiving consultation or Treatment (therein listing the Physicians, Hospitals and other healthcare providers within the PPO network by location and specialty), or may visit the Plan Administrator’s website at http://www.imglobal.com to obtain such information.