BENEFIT PERIOD & HOME COUNTRY COVERAGE

BENEFIT PERIOD

While the certificate is in effect, the benefit period does not apply. Upon termination of the certificate, in accordance with this provision, we will pay eligible medical expenses for up to 60 days beginning on the first day of diagnosis or treatment of a covered injury or illness while you are outside your home country and while this certificate is in effect. The benefit period applies only to eligible medical expenses related to a condition for which you are hospitalized as an inpatient on the termination date of the certificate.

In the event you begin a benefit period while the certificate is in effect, and the certificate terminates because you return to your home country, we will pay eligible medical expenses which are incurred in your home country during the benefit period. Home country coverage applies only to eligible medical expenses for which you are hospitalized as an inpatient on the termination date of the certificate.

INCIDENTAL HOME COUNTRY COVERAGE

For every three-month period during which you are covered, you are eligible for up to a maximum of 15 days of coverage in your home country for eligible medical expenses. Any benefit accrued under a single three-month period does not accumulate to another period. Failure to continue your international trip or your return to your home country for the sole purpose of obtaining treatment for an illness or injury that began while traveling shall void any home country coverage provided under the terms of this agreement.

For all non-U.S. citizens electing coverage “Excluding the U.S.” and for all U.S. citizens or residents, no coverage is provided within the U.S., except for U.S. citizens or residents during an eligible incidental home country visit or an eligible benefit period.

Except for a benefit period, coverage provided under this Master Policy is for a maximum duration of 364 days. Any extension is based upon the eligibility rules in force and is solely at our discretion. Notwithstanding the foregoing, coverage under all plans shall terminate on the date we, at our sole option, elect to cancel all members of the same sex, age, class or geographic location, provided we give no less than 30 days advance written notice by mail to your last known address.

MEMBER ELIGIBILITY

ELIGIBILITY

A. Participant

1. You must be under age 65; and

a. A full-time student at a college or university (excluding online colleges and universities); or

b. Within 31 days of being a full-time student at a college or university; or

c. A student under age 19 enrolled in a secondary school; or

d. A full-time scholar affiliated with an educational institution and performing work or research for at least 30 hours per week; and 2. You must be residing outside your home country for the purpose of pursuing international educational activities; and

3. You must not have obtained residency status in your host country; and

4. If in the U.S., you must hold a valid education-related visa. A copy of the I-20 or DS2019 may be requested. J-1 and F-1 visa holders: The full-time student/scholar status requirement is waived within the U.S. if you have a valid F-1 visa (including OPT) or a J-1 visa. Full-time status requirements remain in force for individuals holding M-1, or other category visas. B. Dependents 1. You be the participant’s legally married spouse, or must be the participant’s unmarried child under age 19 years and chiefly dependent on the participant for support and maintenance; and

J-1 and F-1 visa holders: The full-time student/scholar status requirement is waived within the U.S. if you have a valid F-1 visa (including OPT) or a J-1 visa. Full-time status requirements remain in force for individuals holding M-1, or other category visas.

B. Dependents

1. You be the participant’s legally married spouse, or must be the participant’s unmarried child under age 19 years and chiefly dependent on the participant for support and maintenance; and

2. You must accompany the participant abroad on a similar visa or passport while the participant engages in international educational activities; and

3. You must be temporarily located outside the participant’s home country; and

4. You must not have obtained residency status in the host country.

C. Special Conditions for Newborn or Adopted Children:

1. Newborn or adopted children will be automatically covered as dependents for the first 31 days of life provided that the delivery is covered by this insurance or placement occurs while the participant’s coverage is in effect. If the delivery of the newborn is not covered under this insurance, the newborn is eligible for coverage beginning at 14 days of age.

2. Newborn and adopted children must be enrolled within the first 31 days after birth for newborns or within 31 days of placement for adoptions. Enrollment requires written notification of the new dependent’s name, birth date, gender, and citizenship as well as payment of any additional premium due.

3. If a newborn or adopted child is not enrolled by the 31st day following birth (for newborns) or placement (for adopted children), then coverage terminates on the 31st day.

DEFINITIONS

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

Alcohol Abuse means any pattern of pathological use of alcohol that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn

Beneficiary means the individual named in your application to be the recipient of any Accidental Death or Common Carrier Accidental Death benefit. If you do not designate a beneficiary on the application, the beneficiary is automatically as follows:

Members age 18 or older: 1. Spouse (if any), 2. Children (if any) equally, 3. Your estate.

Members under age 18: 1. Custodial Parent(s) (if any), 2. Siblings (if any) equally, 3. Your estate. Certificate means the document issued to you that provides evidence of benefits payable under the Master Policy.

Certificate Period means the period of time beginning on the date and time of the certificate effective date and ending on the date and time of the certificate termination date.

Coinsurance means your payment of eligible expenses at the percentage specified in the Schedule of Benefits and Limits.

Custodial Care means that type of care or service, wherever furnished and by whatever name called, that is designed primarily to assist you in performing the activities of daily living. Custodial care also includes nonacute care for the comatose, semi-comatose, paralyzed or mentally incompetent patients.

Cyber means the use or operations, as a means for inflicting harm, of any computer, computer software program, malicious code, computer virus or process or any other electronic system.

Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and Limits that you must pay per certificate period before eligible expenses are paid.

Dental Treatment means the care of teeth, gums or bones supporting the teeth, including dentures and preparation for dentures.

Dependent means the participant’s legally married spouse, or the participant’s unmarried child under age 19 years and chiefly dependent on the participant for support and maintenance, who is enrolled for coverage under this plan.

Drug Abuse means any pattern of pathological use of a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.

Durable Medical Equipment means a standard basic hospital bed and/or a standard basic wheelchair.

Educational or Rehabilitative Care means care for restoration (by education or training) of one’s ability to function in a normal or near normal manner following an illness or injury. This type of care includes, but is not limited to, vocational or occupational therapy and speech therapy.

Emergency means a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing your life or limb in danger if medical attention is not provided within 24 hours.

Extended Care Facility means an institution, or a distinct part of an institution, which is licensed as a hospital, extended care facility or rehabilitation facility by the state in which it operates; and is regularly engaged in providing 24-hour skilled nursing care under the regular supervision of a physician and the direct supervision of a registered nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a physician; and provides each patient with active treatment of an illness or injury. Extended care facility does not include a facility primarily for rest, the aged, substance abuse treatment, custodial care, nursing care or for care of mental health disorders or the mentally incompetent.

Full-time Scholar means an individual who is affiliated with an educational institution and is engaging in educational activities for at least 30 hours per week. These activities may include but not be limited to performing research in an area of specialty or teaching for a temporary period of time.

Full-time Student means a student at a college or university who is taking 10 credit hours (undergraduate students) or 6 credit hours (graduate students). Full-time student status for individuals enrolled at colleges or universities that do not use a credit hour system must provide documentation of full-time student status.

Home Country means, for U.S. Citizens, the United States of America, regardless of the location of your principal residence. For non-U.S. Citizens, home country is the country where you principally reside and receive regular mail.

Home Health Care Agency means a public or private agency or one of its subdivisions, which operates pursuant to law and is regularly engaged in providing home nursing care under the supervision of a registered nurse, and maintains a daily record on each patient, and provides each patient with a planned program of observation and treatment by a physician.

Home Nursing Care means services provided by a home health care agency and supervised by a registered nurse, which are directed toward the personal care of a patient, provided always that such care is provided in lieu of medically necessary inpatient care in a hospital.

Hospital means an institution which operates as a hospital pursuant to law, and is licensed by the state or country in which it operates; and operates primarily for the reception, care and treatment of sick or injured persons as inpatients; and provides 24-hour nursing service by registered nurses on duty or call; and has a staff of one or more physicians available at all times; and provides organized facilities and equipment for diagnosis and treatment of acute medical conditions on its premises; and is not primarily a rehabilitation facility, longterm care facility, extended care facility, nursing, rest, custodial care or convalescent home, a place for the aged, drug addicts, alcoholics or runaways; or similar establishment.

 Host Country means the country, other than the home country, in which you will engage in educational pursuits. For legal residents and citizens of the U.S., the host country must be outside the U.S., including the U.S. Virgin Islands, Puerto Rico, Guam, American Samoa, and the Northern Mariana Islands.

Illness means a sickness, disorder, illness, pathology, abnormality, ailment, disease or any other medical, physical or health condition. Illness does not include learning disabilities, attitudinal disorders or disciplinary problems.

Injury means an unexpected and unforeseen harm to the body caused by an accident that requires medical treatment.

Inpatient means a person who is an overnight resident patient of a hospital, using and being charged for room and board, or a patient held for observation in a hospital for at least 12 hours.

Intensive Care Unit means a cardiac care unit or other unit or area of a hospital that meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.

Investigational, Experimental or for Research Purposes means procedures, services or supplies that are by nature or composition, or are used or applied, in a way which deviates from generally accepted standards of current medical practice.

Medically Necessary means a service or supply which is necessary and appropriate for the diagnosis or treatment of an illness or injury based on generally accepted current medical practice as determined by us. A service or supply will not be considered medically necessary if is provided only as a convenience to you or the provider, and/or is not appropriate for your diagnosis or symptoms, and/or exceeds in scope, duration or intensity that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment of an illness or injury.

Member means an individual who is covered under this insurance.

Mental Health Disorder means a mental or emotional disease or disorder which generally denotes a disease of the brain with predominant behavioral symptoms; or a disease of the mind or personality, evidenced by abnormal behavior; or a disorder of conduct evidenced by socially deviant behavior. Mental health disorders include: psychosis, depression, schizophrenia, bipolar affective disorder, and those psychiatric illnesses listed in the current edition of the diagnostic and Statistical Manual for Mental Disorders of the American Psychiatric Association.

Outpatient means a member who receives medically necessary treatment by a physician for injury or illness that does not require overnight stay in a hospital.

Participant means the full-time student or full-time scholar who is pursuing international educational activities outside of his/her home country and who is enrolled for coverage under this plan.

Physician means a Doctor of Medicine (MD), Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DDM), Doctor of Podiatry (DPM), Doctor of Osteopathy (DO), a licensed Physical Therapist or Physiotherapist, and a Doctor of Psychiatry (Psy.D) and a Doctor of Psychology (Ph.D.). Physician also includes a Certified Nurse Practitioner (CNP), Certified Registered Nurse Anesthetist (CRNA), Nurse Midwife or a Physician Assistant (PA) under the direction of a medical doctor. A physician must be currently licensed by the jurisdiction in which the services are provided, and the services must be within the scope of that license and covered under this Master Policy.

Relative means biological or step parent current spouse, biological or stepsiblings, or child or stepchild, age 18 or older.

Routine Physical Exam means and examination of the physical body by a physician for preventative or informative purposes only, and not for the diagnosis or treatment of any condition. Routine physical exam also includes diagnostic labs, x-rays, and other procedures for screening, preventative, or informative purposes, but does not include vaccinations.

Sexually Transmitted Diseases means diseases including but not limited to syphilis, chlamydiosis, trichomoniasis, genital herpes, and Human Papillomavirus (HPV).

Student Health Center means a medical facility of an educational institution that provides basic health services for students for a minimum of 10 hours per week during the school semester. Basic services must include staffing by a licensed medical provider (MD, CNP, or RN) for the purpose of assessment and treatment of minor illnesses and injuries and/or referral to another medical provider.

Substance Abuse means alcohol, drug or chemical abuse, overuse or dependency.

Surgery or Surgical Procedure means an invasive diagnostic procedure, or the treatment of illness or injury by manual or instrumental operations performed by a physician while the patient is under general or local anesthesia.

Usual, Reasonable and Customary means the lesser of the following:

1. One and a half times (150%) of the charges payable under the United States Medicare program, for claims incurred outside the PPO network within the U.S., or

2. Most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. What is defined as usual, reasonable and customary charges will be determined by us. In determining whether a charge is usual, reasonable and customary, we may consider one or more of the following factors: the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services; the severity or nature of the illness or injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service,medicine or supply; such other factors we, in the reasonable exercise of discretion, determine are appropriate.

You/Your means each insured person named in the certificate.

We/Us/Our means Tokio Marine HCC - Medical Insurance Services Group.

 

DESCRIPTION OF COVERAGE SUMMARY

 

This Description of Coverage is a summary of the provisions contained in Master Policy No.201920-SUSA. For a complete copy of the Master Policy, please contact Tokio Marine HCC - Medical Insurance Services Group.

This Description is to help you understand the insurance that your certificate provides. It details the key features, benefits, limitations, exclusions, definitions, Schedule of Benefits and Limits, and any endorsements, applying to your certificate

The levels of coverage which apply to your coverage are detailed in the Schedule of Benefits and Limits.

 

IMPORTANT FEATURES OF YOUR TRAVEL INSURANCE

CANCELLATION

We hope you are happy with the cover this policy provides. However, if after reading it, this insurance does not meet with your requirements, please notify us of your wish to cancel and we will refund your premium.

Premiums will be refunded in full if a cancellation request is received prior to the certificate effective date.

Premiums may be refunded after the certificate effective date subject to the following provisions:

1. A $25 cancellation fee will apply for administrative costs incurred by us; and

2. Only premium for unused whole-months, if paying in monthly installments, or unused days, if paid in full, of the plan will be refunded; and

3. You cannot have filed any claims to be eligible for a premium refund; and

4. No refund of premium shall be granted after 60 days.

APPEALS AND COMPLAINTS

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

DEFINITIONS

This insurance policy has defined terms, indicated by bolded words (excluding headers). The defined terms may be found in the relevant benefit section or in the general definitions.

PRE-EXISTING CONDITIONS

This insurance policy excludes coverage for pre-existing conditions, except an Emergency Medical Evacuation, or Repatriation of Remains, subject to the limits set forth in the Schedule of Benefits and Limits. This policy defines a pre-existing condition. .

DATA PROTECTION

We respect individual privacy and value your confidence. We restrict access to personal information to employees/partners who need to know that information in order to perform their jobs. Any employee that we determine is in violation of this policy will be subject to disciplinary action, up to and including termination and criminal prosecution.

We will not disclose your personal information to third parties outside Tokio Marine HCC and our partners unless ordered to do so to comply with the law of the countries in which we do business or when complying with the legal process.

RIGHTS OF THIRD PARTIES

You may assign benefits under this insurance to a hospital, physician or other provider. Any assignment shall not confer upon such hospital, physician or other provider, any right or privilege granted to you under this insurance except for the right to receive benefits, if any, which are determined to be due and payable hereunder. No hospital, physician or other provider shall have any direct or indirect claim or right of action against us.

LAW AND JURISDICTION

No action of law or equity may be brought to recover benefits under this insurance until 60 days after written proof of claim has been provided to us. No such action may be brought after the end of three (3) years after the time written proof of claim is required to be furnished. The validity, interpretation, and performance of this agreement shall be governed by and construed in accordance with the laws of Bermuda.

ARBITRATION

EXCEPT FOR CERTAIN TYPES OF DISPUTES DESCRIBED IN THE “ARBITRATION AND CLASS ACTION WAIVER”, AND IF YOU DO NOT OPT-OUT AS SET FORTH IN THAT SAME SECTION, YOU AGREE THAT DISPUTES BETWEEN YOU AND THE TOKIO MARINE HCC - MIS GROUP AND/OR THE UNDERWRITERS WILL BE RESOLVED BY BINDING, INDIVIDUAL ARBITRATION, AND YOU WAIVE YOUR RIGHT TO BRING OR RESOLVE ANY DISPUTE AS, OR PARTICIPATE IN, A CLASS, CONSOLIDATED, REPRESENTATIVE, COLLECTIVE, OR PRIVATE ATTORNEY GENERAL ACTION OR ARBITRATION

TOKIO MARINE HCC - MEDICAL INSURANCE SERVICES GROUP (“MIS GROUP”)

A subsidiary of Tokio Marine HCC, HCC Lloyd’s Syndicate 4141 is managed by HCC Underwriting Agency Ltd which is authorized by the Prudential Regulation Authority (PRA) and regulated by the Financial Conduct Authority (FCA) and the PRA. Registered in England and Wales No. 04632146. Registered office: 1 Aldgate, London EC3N 1RE, United Kingdom. Lloyd’s is authorised as an insurer in Spain by the Spanish insurance regulatory authority (Dirección General de Seguros y Fondos de Pensiones) under reference L0017

These details can be checked on the Financial Services Register by visiting: www.fca.org.uk or contacting the Financial Conduct Authority on 0800 111 6768.

IMPORTANT NOTICE AND DISCLAIMER CONCERNING THE UNITED STATES PATIENT PROTECTION AND AFFORDABLE CARE ACT

This insurance is not subject to, and does not provide certain insurance benefits required by the United States’ Patient Protection and Affordable Care Act (“PPACA”). PPACA requires certain US citizens or US residents to obtain PPACA compliant health insurance, or “minimum essential coverage.” PPACA also requires certain employers to offer PPACA compliant insurance coverage to their employees. Tax penalties may be imposed on U.S. residents or citizens who do not maintain minimum essential coverage, and on certain employers who do not offer PPACA compliant insurance coverage to their employees. In some cases, certain individuals may be deemed to have minimum essential coverage under PPACA even if their insurance coverage does not provide all of the benefits required by PPACA. You should consult your attorney or tax professional to determine whether this policy meets any obligations you may have under PPACA.

SCHEDULE OF BENEFITS AND LIMITS

Plan Details

 

Overall Maximum Limit

$3,000,000

Maximum per Injury / Illness

$500,000

Deductibles (except Emergency Room)

$25 per injury or illness within the Preferred Provider Organization (PPO) network or student health center; otherwise $100 per injury or Illness.

If treatment received outside of U.S., $25 per illness or injury

Emergency Room Deductible (claims incurred in U.S. only)

$100 for treatment received in an emergency room unless admitted as inpatient

Coinsurance - Claims Incurred in the U.S.

 

In-Network Payment

Within the PPO: We will pay 85% of the next $10,000 of eligible expenses, after the deductible, then 100% up to the overall maximum limit.

Out-Of-Network Payment

Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount

Coinsurance - Claims Incurred Outside the U.S.

We will pay 100% of eligible expenses, after the deductible, up to the overall maximum limit

Hospital Room and Board

Average semi-private room rate, including nursing services

Intensive Care Unit

Up to the overall maximum limit

Local Ambulance

Up to $350 per injury or illness, when covered illness or injury results in hospitalization as inpatient. - not subject to coinsurance

Outpatient Treatment

Up to the overall maximum limit

Outpatient Prescription Drugs

Generic Drugs: $15 deductible per prescription

Brand Name Drugs: $30 deductible per prescription

Outpatient Physical Therapy & Chiropractic Care

Up to $75 per visit per day - not subject to coinsurance

Must be ordered in advance by a physician and not obtained at a student health center

Optional Intercollegiate, Interscholastic, Intramural, or Club Sports Rider

Up to $10,000 maximum per injury or illness, medical expenses only.

Sports & Activities - Leisure, Recreational, Entertainment, or Fitness

Optional Intercollegiate, Interscholastic, Intramural, or Club Sports Rider

Up to the overall maximum limit

 

Up to $10,000 maximum per injury or illness, medical expenses only.

Mental Health Disorders (excludes drug abuse and alcohol abuse)

We will pay:

Within the PPO: 80% of eligible expenses, after the deductible, up to the overall maximum.

Outside the PPO: Usual, reasonable, and customary up to the overall maximum. You may be responsible for any charges exceeding the payable amount.

Outside the U.S.: 100% coinsurance, after the deductible, up to the overall maximum.

Outpatient: Maximum of 30 visits.

Inpatient: Maximum of 30 days.

Treatment must not be provided at a student health center.

Maternity Care for a Covered Pregnancy

We will pay:

Within the PPO: 80% of eligible expenses, after the deductible, up to $20,000.

Outside the PPO: Usual, reasonable, and customary up to $20,000. You may be responsible for any charges exceeding the payable amount.

Outside the U.S.: 100% coinsurance, after the deductible, up to $20,000.

Nursery Care of Newborn

Up to $750 - not subject to coinsurance

Therapeutic Termination of Pregnancy

Up to $500 - not subject to coinsurance

Dental Treatment due to Accident

Up to $1,000 maximum per certificate period - not subject to coinsurance

Emergency Dental (Acute Onset of Pain)

Up to $100 - not subject to deductible or coinsurance

Wellness

100% of one routine physical exam per member

Optional Vaccination Benefit Rider

Up to $150. Covered vaccinations and testing are: Measles, Mumps, Rubella (MMR); Tetanus/Diphtheria/Pertussis (TDAP); Chicken Pox (Varicella); Hepatitis B; and Meningitis (Meningococcal MCV4 and B) - not subject to deductible or coinsurance

All Other Eligible Medical Expenses

Up to the overall maximum limit

Terrorism

Up to $50,000 lifetime maximum, eligible medical expenses only.

Emergency Travel Benefits

Limit

Emergency Medical Evacuation

Up to $500,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Repatriation of Remains

Up to $50,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit

Emergency Reunion

Up to $5,000, subject to a maximum of 15 days - not subject to deductible, coinsurance, or overall maximum limit

Accidental Death & Dismemberment

Lifetime Maximum - $25,000

Death - $25,000

Loss of 2 Limbs - $25,000

Loss of 1 Limb - $12,500

- not subject to deductible, coinsurance, or overall maximum limit

Personal Liability

Up to $150,000 lifetime maximum

Up to $150,000 third person injury

Up to $150,000 third person property

$1,500 related third person property

- not subject to deductible, coinsurance, or overall maximum limit

General Exclusions
Excluded Conditions, Treatments (includes Diagnoses, Tests, and Examinations), Services, Supplies, Acts, Omissions, and/or Events:
1. Pre-existing Conditions during the first six (6) months of coverage, except charges resulting directly from an Emergency Medical Evacuation or Repatriation of Remains, subject to the limits set forth in the Schedule of Benefits and Limits.
2. Congenital illnesses.
3. Routine physical exams, and other diagnostic labs, x-rays, and procedures for screening or preventative purposes, except as provided for under the Wellness benefit.
4. Vaccinations except as provided for under the Optional Vaccination Benefit Rider if elected.
5. Dental treatment and treatment of the temporomandibular joint, except for emergency dental treatment necessary to replace natural teeth lost or damaged in an accident covered hereunder or for the emergency relief of acute onset of pain.
6. Mental health disorders if treatment is obtained at a student health center.
7. Physical therapy if treatment is obtained at a student health center.
8. Chiropractic treatment, unless ordered in advance by a physician for medically necessary treatment related to a covered injury or illness, and not obtained at a student health center.
9. Routine pre-natal care, pregnancy, childbirth, post-natal care, and nursery care of a newborn, unless directly related to a covered pregnancy.
10. Elective termination of pregnancy.
11. Promotion or prevention of conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
12. All sexually transmitted diseases and conditions.
13. HIV, AIDS, or ARC, and all diseases caused by and/or related to HIV.
14. Organ or tissue transplants or related services.
15. Self-inflicted injury or illness and/or suicide or attempted suicide whether sane or insane.
16. Injury sustained that is due wholly or partially to the effects of intoxication or drugs other than drugs taken in accordance with treatment prescribed by a physician and except drugs prescribed for the treatment of substance abuse.
17. Voluntarily using any drug, narcotic or controlled substance, unless as prescribed by a physician.
18. Charges resulting from or occurring during the commission of a violation of law, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
19. Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
20. Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations.
21. Orthoptics and visual eye training.
22. Orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or toenails.
23. Hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed.
24. Acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, hypertrophic and atrophic conditions of skin, nevus.
25. Sleep apnea or other sleep disorders.
26. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.
27. Psychometric, intelligence, competency, behavioral and educational testing.
28. While confined primarily to receive custodial care, educational or rehabilitative care, or any medical treatment in any establishment for the care of the aged, except rehabilitative care received upon direct transfer from an acute care hospital.
29. Cosmetic or aesthetic reasons, except for reconstructive surgery when such surgery is directly related to and follows a surgery which was covered hereunder.
30. Modifications of the physical body intended to improve the psychological, mental or emotional well- being, including but not limited to sex-change surgery.
31. Obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass surgery.
32. Exercise programs, whether or not prescribed or recommended by a physician.
33. Incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
34. Any illness or injury incurred as a result of epidemics, pandemics, public health emergencies, natural disasters, or other disease outbreak conditions that may affect a person’s health when, prior to your effective date, any of the following were issued:
a.  The United States Centers for Disease Control & Prevention had issued a Warning/Alert Level 3 or higher for a location or destination, including common carriers; or
b.  The United States Centers for Disease Control & Prevention had issued a Global or Worldwide Warning/Alert Level 3 or higher.
This exclusion is applicable when 1) any of the above were in effect within 60 days immediately prior to your effective date or 2) within 10 days following the date the alert/warning is issued you have failed to depart the country or location. This exclusion does not apply to charges resulting from COVID-19/SARS- CoV-2.
35. Investigational, experimental or for research purposes.
36. Complications or consequences of a treatment or condition not covered hereunder.
37. Incurred outside your certificate period.
38. Submitted to us for payment more than 60 days after the last day of the certificate period.
39. Exceeding usual, reasonable and customary.
40. Not medically necessary.
41. Not administered by or ordered by a physician.
42. Provided by a relative, family member or any person who ordinarily resides with you.
43. Provided at no cost to you.
44. Failure to keep a scheduled appointment.
45. When departure from the home country is to obtain treatment in the destination country/countries.
46. Travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Repatriation of Remains, and Emergency Reunion sections of this insurance.
47. Payable under any government system, including the Australian Medicare system.
48. Payable under Worker’s Compensation or Employer’s Liability Laws, or by any coverage provided or required by law.
49. War, military action or while on duty as a member of a police or military force unit.
50. Not included as Eligible Expenses as described herein.

PRE-EXISTING MEDICAL CONDITIONS

Charges resulting directly or indirectly from any pre-existing conditions are excluded from this insurance except charges resulting directly from an Emergency Medical Evacuation, or Repatriation of Remains, subject to the limits set forth in the Schedule of Benefits and Limits.

Pre-existing Condition means any

(1)    condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the 12 months immediately preceding the certificate effective date;

(2)    condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 12 months immediately preceding the certificate effective date;

(3)    injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 12 months immediately preceding the certificate effective date.

 

 

U.S. Preferred Provider Organization (PPO)
This insurance policy offers the option of a PPO network for medical treatment received in the United States. If you choose to seek treatment from a PPO provider, billed charges for eligible expenses may be reduced and we will remit payment directly to the provider. Additionally, we will apply the in-network coinsurance applicable to the expenses.


You may review a listing of hospitals, physicians and other medical service providers included in the PPO Network for the area where you will be receiving treatment by accessing the Internet website for WorldTrips: www.worldtrips.com. For assistance locating a provider, contact us at 1-800-605-2282.


U.S. Preferred Provider Organization (PPO) Requirements
Nothing contained in this insurance restricts or interferes with your right to select the hospital, physician or other medical service provider of your choice. Nothing contained in this insurance restricts or interferes with the relationship between you and the hospital, physician or other providers with respect to treatment or care of any condition, nor your right to receive, at your own expense, services and/or supplies that are not covered under this insurance.


To comply with the United States Preferred Provider Organization (PPO) requirements, you must receive medical treatment from PPO providers while in the United States. If you received treatment from a PPO provider, we will waive the coinsurance applicable to the expenses.
You may review a listing of hospitals, physicians and other medical service providers included in the PPO Network for the area where you will be receiving treatment by visiting WorldTrips’ website located at: www.worldtrips.com. For assistance locating a provider, contact us at 1-800-605-2282.

Renewable

This plan can be purchased from 30 to 364 consecutive days of coverage, renewable for up to 4 years.

Cancellation
We hope you are happy with the cover this policy provides. However, if after reading it, this insurance does not meet with your requirements, please notify us of your wish to cancel and we will refund your premium.
Premiums will be refunded in full if a cancellation request is received prior to the certificate effective date. Premiums may be refunded after the certificate effective date subject to the following provisions:

  1. A $25 cancellation fee will apply for administrative costs incurred by us; and
  2. Only premium for unused whole-months, if paying in monthly installments, or unused days, if paid in full, of the premium will be refunded; and
  3. You cannot have filed any claims to be eligible for a premium refund; and
  4. No refund of premium shall be granted after 60 days.

Claim

Claims
This insurance policy has in it a Claims Procedure which tells you what steps you must take to file a claim, and explains our obligations to you. Beginning on the last day of your certificate period, you shall have 60 days to provide us proof of claim.

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

Rights of Third Parties
You may assign benefits under this insurance to a hospital, physician or other provider. Any assignment shall not confer upon such hospital, physician or other provider, any right or privilege granted to you under this insurance except for the right to receive benefits, if any, which are determined to be due and payable hereunder. No hospital, physician or other provider shall have any direct or indirect claim or right of action against us.


Claim Procedures
Claims Notification
All claims and related claim information, including a proof of claim, should be submitted to the Company at the contact information below, or online at http://service.worldtrips.com/ as soon as possible.

 

Online: http://service.worldtrips.com/

Postal Mail:        WorldTrips

P.O. Box 2005

Farmington Hills, MI 48333

USA


Proof of Claim
You must send proof of claim for any expenses that you are requesting to be paid by us. This includes treatment or services for which the medical provider bills us directly. No payments will be made by us without you first submitting a proof of claim.

We must receive proof of claim within 60 days of the last day of your certificate period (or for claims incurred during a benefit period, 60 days from the date the claim is incurred).


A proof of claim must include all the following:

  1. A completed and signed Claimant’s Statement and Authorization form, together with any/all required attachments;
  2. Itemized bills from physicians, hospitals and other medical providers; and
  3. Receipts for any expenses which have already been paid by you or on your behalf.

Subsequent to receipt of proof of claim, we may, at our sole discretion, request and require additional information, including but not limited to medical records, necessary to confirm whether coverage exists for any claim prior to payment thereof.


Claims Cooperation
You shall provide assistance and co-operate with us or our representatives in obtaining any other records we or they feel necessary to evaluate your claim or any incident giving rise to your claim. You shall provide, when asked, all authorizations necessary to obtain your medical records. If you do not fully co-operate with us and/or our investigation of the claim, we shall not be liable to pay any claim.


Access to Additional Materials
You shall provide us, or our designated representatives, all information, documentation and medical information that we or they may reasonably require during the term of this policy, or until all claims have been resolved, whichever is later.


Other Insurance
We shall not pay any claim if there is other insurance which would, or would but for the existence of this insurance, pay such claim. This insurance will apply with respect to expenses in excess of the amount paid or payable under such other insurance. We shall not pay any claim in respect to care, treatment, services or supplies furnished by any insurance, program or agency funded by any government.

Appeal and Complaints Procedure
Appealing a Claim
In the event we deny all or part of a claim under this insurance, you may file a written appeal with us. The written appeal must include sufficient information to identify the claim under appeal and must specify the reason(s) for the appeal with supporting documentation, if applicable.


Please submit your written appeal online, by email, or by postal mail at the following:

Online: http://service.worldtrips.com/

Email: appeals@worldtrips.com

Postal Mail:    WorldTrips Appeals

P.O. Box 2058

Farmington Hills, MI 48333

USA


When we receive the appeal, we will review the claim and a written response will be sent to you. After you receive our response to the appeal, you may initiate a second appeal. With our receipt of the second appeal, medical and/or claims personnel who were not involved in the original claim determination or the initial appeal will review the claim. A final determination will be made and a letter will be sent to you.

Please note that appealing a claim is not a requirement to following the complaints procedure detailed below.


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

Please send your written complaint online, by email, or by postal mail at the following:

Online: http://service.worldtrips.com/ 

Email: appeals@worldtrips.com

Postal Mail:    WorldTrips Appeals

P.O. Box 2058

Farmington Hills, MI 48333

USA


We will acknowledge receipt of your complaint promptly after receiving it.

If you are a UK citizen and you have not been given an answer within 8 (eight) weeks or should you remain dissatisfied, you may refer your complaint to Lloyd’s, who will investigate and assess your complaint. Lloyd’s contact details are as follows:

Complaints

Lloyd’s

One Lime Street

London EC3M 7HA

Email:    complaints@lloyds.com

Telephone:    +44 (0)20 7327 5693

Fax:    +44 (0)20 7327 5225

Web:    www.lloyds.com/complaints

This complaints procedure does not affect any legal right you have to take action. Once you have received your final response from Lloyd’s, and if you are still not satisfied you can contact the Financial Ombudsman Service:

 

Financial Ombudsman Service

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

Phone: +44 (0) 20 7964 0500

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


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