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) 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

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

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

(4) be an individual at least fourteen (14) days old

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

(6) not be Pregnant, Hospitalized or Disabled on the Initial Effective Date

(7) not be HIV + on the Initial Effective Date

(8) not have established a permanent residency in the Destination Country

 

 

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 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

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

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

(i) the next day following the maximum time period pursuant to the CONDITIONS AND GENERAL PROVISIONS, RENEWAL; AMENDMENTS provision

(j) 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.

 

Acute Onset of Pre-existing Condition: A sudden and Unexpected outbreak or reoccurrence that is of short duration, is rapidly progressive, and requires urgent medical care. A Pre-existing Condition that is chronic or congenital, or that gradually becomes worse over time is not an Acute Onset of Pre-existing Condition. An Acute Onset of Pre-existing Condition does not include any condition for which, as of the Effective date, the Insured Person (i) knew or reasonably foresaw he/she would receive, (ii) knew he/she should receive, (iii) had scheduled, or (iv) were told that he/she must or should receive, any medical care, drugs or Treatment.

 

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; 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.

 

Checked Luggage: The Insured Person’s Luggage placed in possession of the Common Carrier during travel in exchange for a receipt for the Luggage.

 

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.

 

Convalescent: Treatment, services and supplies provided to aid in the recovery of a patient to reach a degree of body functioning to permit self-care in essential daily activities.

 

Copayment: The amount the Insured Person is responsible to pay for each Urgent Care or Walk-in Clinic visit.

 

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.

 

Disabled: A person who has a congenital or acquired mental or physical defect that interferes with normal functioning of the body system or the ability to be self-sufficient.

 

Durable Medical Equipment (DME): Exclusively the following items: a standard basic hospital bed and/or a standard basic wheelchair.

 

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, his/her Spouse, and any Child or Children who are covered as an Insured Person 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. Hospice Care must be certified by a Physician and life expectancy is six (6) months or less.

 

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.

 

Imminent Bodily Harm: The existence of any condition or circumstance that cannot be avoided through reasonable precautionary measures and could be expected to cause death or serious physical harm to the Insured Person if the Insured Person were to remain in the affected area where the Natural Disaster event has occurred.

 

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.

 

Interfacility Ambulance Transfer: Movement of the patient locally within the United States from one licensed health care Facility to another licensed health care Facility via air or land ambulance (examples: Hospital to Hospital, clinic to Hospital,

Hospital to Extended Care Facility). The Interfacility Ambulance Transfer must be Medically Necessary and Pre-certified in advance to be an Eligible Medical Expense.

 

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.

 

Luggage: Bags, cases, and containers that hold clothing, personal items and toiletries while the Insured Person is traveling.

 

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.

 

Natural Disaster: Widespread disruption of human lives by disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm, or other storm, landslide, or other natural catastrophe or event resulting in migration of the human population for its safety. The occurrence must be a disaster that is due entirely to the forces of nature and could not reasonably have been prevented.

 

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 period beginning on the Effective Date of Coverage of this Certificate and ending on the earliest of the following dates:

(a) the termination date specified in the Declaration; or

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

The Period of Coverage can be no less than five (5) days and no more than twelve (12) consecutive months.

 

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.

 

Pregnancy; Pregnant: The process of growth and development within a woman’s reproductive organs of a new individual from the time of conception through the phases where the embryo grows and fetus develops to birth.

 

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).

 

Reasonable and Customary: A typical and reasonable amount of reimbursement for similar services in the geographic area in which the Charges are incurred for services related to the necessary notification of the identity theft, such as filing and/or notarizing legal documents, notifying credit reporting agencies, long distance telephone calls and/or postage for mailing documentation.

 

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 or domestic partner. Such relationship must have met all requirements of a valid marriage contract, domestic partnership, or civil union in the state or Country of Residence where the parties’ ceremony was performed.

 

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

 

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.

 

Traumatic Dental Injury: An injury that includes:

(a) Trauma involving the face, skull, neck and/or jaws which resulted in loss of teeth or a serious dental Injury; and

(b) Injury requiring evaluation and Treatment in a Hospital Emergency room or a Hospital confinement setting.

 

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.

 

Uninhabitable: The Insured Person’s location within the Destination Country is deemed unfit for residence, as determined by the Company and local authorities within the Destination Country, due to lack of habitable shelter, food, heat and/or potable water available within one hundred (100) miles of the disaster site.

 

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.

 

Walk-in Clinic: A medical Facility that provides medical services for a minor Injury or Illness. The clinics are often found in or near retail establishments or pharmacies. The staff providing medical services are nurse practitioners and physician assistants.

 

BENEFIT SUMMARY

Coverage Limit / Maximum Amount for Eligible Medical Expenses

Period of Coverage

Five (5) days up to twelve (12) months

Period of Coverage limit

As indicated on the Declaration

• Through age 69: $2,000,000, $5,000,000 or $8,000,000

• Ages 70 to 79: $100,000

• Ages 80 and older: $20,000

Area of Coverage

Worldwide excluding the Insured Person’s Country of Residence

Benefit Plan Features

Benefit Levels

United States

United States

International

In-Network

Out-of-Network

International

Deductible for Eligible Medical Expenses

Deductible

$0, $100, $250, $500, $1,000, $2,500, $5,000, $10,000 or $25,000 per Insured Person, as indicated on the Declaration

Coinsurance for Eligible Medical Expenses

Coinsurance
• In addition to Deductible

Plan pays 100% Insured pays 0%

Plan pays 90% Insured pays 10%

Plan pays 100% Insured pays 0%

Out of Pocket Maximum

$0

$500

$0

Pre-certification

• Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met.

• Medical Evacuation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION provision for complete requirements and coverage.

• All other Treatments & supplies: fifty percent (50%) reduction of Eligible Medical Expenses if Pre-certification requirements are not met.

• Deductible is taken after reduction.

• Coinsurance is applied to remainder of the reduced amount.

• Refer to PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification.

Pre-existing Conditions

 

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 Conditions

Subject to Deductible and Coinsurance unless otherwise noted

Eligible Medical Expenses are limited to Usual, Reasonable and Customary

Limits per Period of Coverage unless stated as Maximum Limit

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

 

United States citizens:

• Age 64 and under without a Primary Health Plan:

• Maximum Limit: $20,000

• Age 64 and under with a Primary Health Plan:

• Maximum Limit: $1,000,000

• Age 65 through age 69:

• Maximum Limit: $2,500

 

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

 

Non-United States citizens:

• Age 69 and under:

• Maximum Limit: $1,000,000

 

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

 

 

Inpatient or Outpatient
Services Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit

Benefit

In-Network

Out-of-Network

International

Eligible Medical Expenses

100%

90%

100%

Physician Visits / Services

100%

90%

100%

Urgent Care Center

• Not subject to Deductible

• Copayment: $25

• Copayment is not applicable if the Declaration states a $0 Deductible

100%

90%

100%

Walk-in Clinic

• Not subject to Deductible

• Copayment $15

• Copayment is not applicable if the Declaration states a $0 Deductible

100%

90%

100%

           

 

Inpatient or Outpatient Services

Subject to Deductible and Coinsurance unless otherwise noted

Eligible Medical Expenses are limited to Usual, Reasonable and Customary

Limits per Period of Coverage unless stated as Maximum Limit

 

Benefit

In-Network

Out-of-Network

International

 

Hospital Emergency Room: United States

• Injury: Not subject to Emergency Room Deductible
• Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does not result in a direct Inpatient Hospital admission

100%

90%

Not Applicable

 

Hospital Emergency Room: International

• Deductible waived

Not Applicable

Not Applicable

Not Applicable

 

Hospitalization / Room & Board

• Average semi-private room rate

• Includes nursing, miscellaneous and Ancillary services

100%

90%

100%

 

Intensive Care

100%

90%

100%

 

Bedside Visit

• Not subject to Deductible

• Maximum Limit: $1,500

• Hospitalized in an Intensive Care Unit

• Refer to the BEDSIDE VISIT provision for further details

100%

90%

100%

 

Outpatient Surgical / Hospital Facility

100%

90%

100%

 

Laboratory

100%

90%

100%

 

Radiology / X-ray

100%

90%

100%

 

Chemotherapy / Radiation Therapy

100%

90%

100%

 

Pre-admission Testing

100%

90%

100%

 

Surgery

100%

90%

100%

 

Reconstructive Surgery

• Surgery is incidental to or follows Surgery that was covered under the Plan

100%

90%

100%

 

Assistant Surgeon

• Twenty percent (20%) of the primary surgeon’s eligible fee

100%

90%

100%

 

Anesthesia

100%

90%

100%

 

Durable Medical Equipment

100%

90%

100%

 

Chiropractic Care

• Medical order or Treatment plan required

100%

90%

100%

 

Physical Therapy

• Medical order or Treatment plan required

100%

90%

100%

 

Extended Care Facility

• Upon direct transfer from an acute care Hospital

100%

90%

100%

 

Home Nursing Care

• Provided by a Home Health Care Agency

• Upon direct transfer from an acute care Hospital

100%

90%

100%

Prescriptions

Subject to Deductible and Coinsurance unless otherwise noted

Eligible Medical Expenses are limited to Usual, Reasonable and Customary

Limits per Period of Coverage unless stated as Maximum Limit

Benefit

In-Network

Out-of-Network

International

Prescriptions

• Dispensing limit: 90 days

Not Applicable

90%

100%

Emergency Services
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit

Emergency Local Ambulance

• Subject to Deductible and Coinsurance

• Injury

• Illness resulting in an Inpatient Hospital admission

Not Applicable

90%

100%

Emergency Medical Evacuation

• Up to the Period of Coverage limit

• Must be approved in advance and coordinated by the Company

100%

100%

100%

Emergency Reunion

• Maximum Limit: $100,000

• Maximum days: 15

• Meal maximum: $25 per day

• Reasonable and necessary travel costs and accommodations

• Must be approved in advance by the Company

100%

100%

100%

Interfacility Ambulance Transfer

• Transfer from one licensed health care Facility to another licensed health care Facility resulting in an Inpatient Hospital admission

100%

100%

100%

Natural Disaster Evacuation

• Maximum Limit: $25,000

• Approved in advance by the Company

100%

100%

100%

Political Evacuation and Repatriation

• Maximum Limit: $100,000

• Must be approved in advance by the Company

100%

100%

100%

Remote Transportation

• Maximum Limit: $20,000

• Limit: $5,000

• Approved in advance by the Company

 

100%

100%

100%

Return of Minor Children

• Maximum Limit: $100,000

• Must be approved in advance by the Company

100%

100%

100%

Return of Mortal Remains

• Up to the Period of Coverage limit

• Local Burial / Cremation Maximum Limit: $5,000

• Return of Insured Person’s Mortal Remains to Country of Residence

• Must be approved in advance by the Company

100%

100%

100%

         

 

Other Services
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit

Benefit

In-Network

Out-of-Network

International

Accidental Death & Dismemberment

• Principal Sum Maximum Limit: $50,000

• Death must occur within ninety (90) days of the Accident

Accidental Death: 100% of Principal Sum

Dismemberment:

Accidental Loss Percent of Principal Sum

Sight of one eye 50% One hand or one foot 50% One hand and the loss of sight of one eye 100%

One foot and the loss of sight of one eye 100%

One hand and one foot 100%

Both hands or both feet 100%

Sight of both eyes 100%

Common Carrier Accidental Death

• Maximum Limit per adult: $100,000

• Maximum Limit per Child: $25,000

• Maximum Limit per Family: $250,000

 

 

100%

 

 

100%

 

100%

 

Dental Treatment

• Subject to Deductible and Coinsurance

• Limit: $300

(Unexpected pain or Treatment due to an Accident)

 

 

Not Applicable

 

 

90%

 

 

100%

 

 

Traumatic Dental Injury

• Subject to Deductible and Coinsurance

• Treatment at a Hospital due to an Accident

• Additional Treatment for the same Injury rendered by a Dental Provider will be paid at one hundred percent (100%)

100%

90%

100%

Hospital Indemnity

• Overnight limit: $250

• Maximum nights: 10

• Outside Insured Person’s Country of Residence and the United States

• Inpatient Hospitalization only

 

 

Not Applicable

 

Not Applicable

 

100%

Emergency Eye Examination

• Subject to Coinsurance

• Deductible per occurrence: $50 (plan Deductible waived)

• Limit: $150

• Loss or damage to prescription corrective lenses due to an Accident

 

Not Applicable

90%

100%

Identity Theft

• Limit: $500

100%

100%

100%

Incidental Trip

• Maximum days: 14

• Insured Person’s Country of Residence is not the United States

 

100%

 

100%

 

100%

Lost Luggage

• Limit: $500

• Limit: $50 per item

100%

100%

100%

Natural Disaster

• Limit per day: $250

• Maximum days: 5

 

100%

100%

100%

Other Services
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit

 

Benefit

In-Network

Out-of-Network

International

 

Personal Liability

• Secondary to any other insurance

• No coverage for Injury to a related Third Party or damage to related Third Person’s property

• Refer to the PERSONAL LIABILITY provision for further details and requirements

Combined Maximum Limit: $25,000

Injury to Third Person:

• Per Injury Deductible: $100

Damage to Third Person’s property:

• Per damage Deductible: $100

Terrorism

• Maximum Limit: $50,000

100%

100%

100%

Non-emergency Medical Evacuation

• Maximum Limit: $50,000

• Insured Persons under age 65

• Approved in advance and coordinated by the Company

 

100%

100%

100%

Pet Return

• Limit: $1,000

• For a pet cat or dog travelling with the Insured Person

 

100%

100%

100%

Supplemental Accident Benefit

• Maximum Limit per covered Accident: $300

 

100%

100%

100%

Small Pet Common Air Carrier Accidental Death Benefit

• Maximum Limit per pet: $500

• For a pet cat or dog up to 30 pounds travelling with the Insured Person

 

100%

100%

100%

Trip Interruption

• Limit: $10,000

100%

100%

100%

 

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 Period of Coverage with respect to an Illness or Injury suffered or sustained by the Insured Person during the Period of Coverage 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 are incurred for Treatment or supplies that are Medically Necessary (“Eligible Medical Expenses”):

Charges incurred at a Hospital for:

(a) daily room and board, nursing services, and Ancillary Services not to exceed the average semi-private room rate. A private room will be considered when no semi-private room is available or if medical necessity warrants this type of room. The private room rate is not to exceed the average private room rate.

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

(c) use of operating, Treatment or recovery room

(d) services and supplies which are routinely provided by the Hospital to persons for use while an Inpatient

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

(f) Emergency Treatment of an Illness; however, an additional Deductible (as shown in the BENEFIT SUMMARY) will be required unless the Insured Person is directly admitted to the Hospital as Inpatient for further Treatment of that Illness

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

(3) Charges by a Physician for professional services rendered, including Surgery; provided, however, that Charges by or for an assistant surgeon will be limited and covered at the rate of up to twenty percent (20%) of the Usual, Reasonable and Customary charge of the primary surgeon; and provided, further, that the standby availability of a Physician or surgeon will not be deemed to be a professional service and is not eligible for coverage

(4) Charges incurred for:

(a) dressings, sutures, casts or other supplies which are Medically Necessary

(b) 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

(c) Implant devices that are Medically Necessary; however, any Implants provided outside the PPO network are limited to a payment of no more than one hundred fifty percent (150%) of the established invoice price and/or list price for that item

(d) basic functional artificial limbs, eye or larynx or breast prostheses, but not the replacement or repair thereof

(e) reconstructive Surgery when the Surgery is incidental to and follows Surgery which was covered hereunder

(f) radiation therapy or Treatment, and chemotherapy (g) hemodialysis for the Treatment of acute renal failure only and the Charges by a Hospital for processing and administration of blood or blood components

(h) oxygen and other gases and their administration

(i) anesthetics and their administration by a Physician

(j) drugs which require 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

(k) care in a licensed Extended Care Facility upon direct transfer from an acute care Hospital

(l) 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

(m) Emergency Local Ambulance Transport necessarily incurred in connection with:

(i) an Injury

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

(n) Interfacility Ambulance Transfer must be a result of an Inpatient Hospital Admission, Medically Necessary and from one licensed health care Facility to another licensed health care Facility via air or land ambulance

(o) chiropractic services prescribed by a Physician and performed by a professional chiropractor, and necessarily incurred to continue recovery from a covered Injury or covered Illness; services include manipulations, x-rays and laboratory tests ordered by the chiropractor

(p) 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

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

(5) Charges incurred for Treatment at an Urgent Care Center

(6) Charges incurred for Treatment at a Walk-in Clinic

(7) Charges for Treatment of an Injury to the foot due to an Accident covered hereunder

(8) Charges for Treatment of an Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of Treatment

(9) Charges for Dental Treatment as follows up to the amount shown in the BENEFIT SUMMARY:

(a) Charges for Treatment following Traumatic Dental Injury from a covered Accident that resulted in physical Injury to the Insured Person

(b) Charges for necessary Dental Treatment of Unexpected pain to sound natural teeth

(c) Charges incurred for non-emergency Dental Treatment necessary due to an Accident covered hereunder

(10) Charges for value-added tax (VAT) or like tax incurred on Eligible Medical Expenses

(11) Charges for an Emergency eye examination performed by a licensed optometrist or ophthalmologist to obtain a Medically Necessary prescription for corrective lenses that were lost or damaged due to an Accident covered hereunder, but not for the replacement of prescription corrective lenses or contact lenses

 

 

 

ACCIDENTAL DEATH AND DISMEMBERMENT:

ACCIDENTAL DEATH: Subject to the Terms of this insurance, and in the event the Insured Person has an Accident during the Period of Coverage which results in death during the Period of Coverage, the Company will pay an Accidental Death benefit in the amount of the Principal Sum shown in the BENEFIT SUMMARY.

The Insured Person’s death must occur within ninety (90) days of the Accident and result, directly and independently of all other causes, from an accidental bodily Injury which is unintended, unexpected, and unforeseen. The bodily Injury must be evidenced by a visible contusion or wound, except in the case of accidental drowning. The bodily Injury must be the sole cause of death. 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; or

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

(c) the Insured Person’s estate; or

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

DISMEMBERMENT: Subject to the Terms of this insurance and if the Insured Person has an Accident during the Period of Coverage which results in a loss identified in the BENEFIT SUMMARY within ninety (90) days from the date of the Accident and during the Period of Coverage, the Company will reimburse the Insured Person the applicable loss/dismemberment shown in the BENEFIT SUMMARY.

The maximum benefit payable for all dismemberments or losses resulting from any one (1) Accident or Injury shall not exceed the Principal Sum shown in the BENEFIT SUMMARY for Accidental Death.

The loss of a hand or foot means the complete severance at or above the wrist or ankle joint. The loss of sight means the entire and irrecoverable loss of sight. The Insured Person’s dismemberment must result, directly and independently of all other causes, from an accidental bodily Injury which is unintended, unexpected, and unforeseen. The bodily Injury must be evidenced by a visible contusion or wound. The bodily Injury must be the sole cause of dismemberment.

 

BEDSIDE VISIT: Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and if the Insured Person is Hospitalized as an Inpatient in the Intensive Care unit of a Hospital for a covered life-threatening Injury or Illness during the Period of Coverage, the Company will reimburse the cost of a round-trip economy commercial airline ticket for one (1) Relative from the airport nearest to the location of the Relative at the time of the Insured Person’s Inpatient Intensive Care Hospitalization to the airport serving the area where the Insured Person is Hospitalized

 

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 Period of Coverage as a result of an Accident that occurred during the Period of Coverage 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.

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; or

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

(c) the Insured Person’s estate; or

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

EMERGENCY MEDICAL EVACUATION:

Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and the CONDITIONS AND RESTRICTIONS subparagraph 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 occurring while this Certificate is in effect and during the Period of Coverage:

(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) Medically Necessary Treatment cannot be provided locally

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

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

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

(e) 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

(f) 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 which 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.

G)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 which 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 thirdparty 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.

he 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.

EMERGENCY REUNION:

Subject to the Terms of this insurance, including without limitation the CONDITIONS AND RESTRICTIONS subparagraph below, Emergency Reunion expenses will be reimbursed to an Insured Person as outlined in the BENEFIT SUMMARY, in cases where there has been an Emergency Medical Evacuation covered under the Terms of this insurance. Subject to the applicable Deductible and Coinsurance and other limits and sub-limits as specified in the BENEFIT SUMMARY, and subject to the CONDITIONS AND RESTRICTIONS subparagraph below, the following costs and expenses incurred in respect of travel by a Relative or friend of the Insured Person will be reimbursable to the Insured Person upon the recommendation and prior approval of the Company

a) the cost of a round-trip economy commercial airline ticket for one (1) Relative or friend from the airport nearest to the location of the Relative or friend at the time of the Emergency to the airport serving the area where the Insured Person is Hospitalized as a result of the Emergency or is to be Hospitalized as a result of the Emergency Medical Evacuation (to be determined pursuant to the Terms of the CONDITIONS AND RESTRICTIONS, subparagraph below), and return from whichever of such locations is actually selected to the point of the original departure

b) reasonable and necessary travel costs, meals (up to the amount shown in the BENEFIT SUMMARY), transportation and accommodation expenses incurred in relation to the Emergency Reunion (but excluding entertainment).

CONDITIONS AND RESTRICTIONS:

(a) The allowable maximum coverage for the Emergency Reunion shall not exceed fifteen (15) days, including travel days, and all costs and expenses incurred beyond such Period of Coverage shall be retained for the sole account and responsibility of the Insured Person, Relative, or friend

(b) the Emergency Reunion must be due to an Emergency Medical Evacuation covered under the Terms of this insurance

(c) the Insured Person must be so seriously ill that the attending Physician deems it necessary and recommends the presence of a Relative or friend at either the location where the Insured Person is being evacuated from or the destination of the Emergency Medical Evacuation, whichever is considered by the attending Physician and the Company to be the more reasonable

(d) all Emergency Reunion travel, transportation and accommodation arrangements and benefits must be approved in advance by the Company in order to be eligible for coverage under this insurance

(e) The Insured Person, Relative and/or friend must submit to the Company upon completion of the Emergency Reunion travel legible and verifiable copies of all paid receipts for the travel and transportation costs and expenses so incurred for which reimbursement is sought.

HOSPITAL INDEMNITY: Subject to the Terms of this insurance and in the event the Insured Person has been Hospitalized in a Facility outside the Country of Residence and the United States, during the Period of Coverage, the Company will pay the Insured Person the amount shown in the BENEFIT SUMMARY for each overnight Hospitalization as an Inpatient, so long as the Treatment received during the overnight Hospitalization is considered to be an Eligible Medical Expense

IDENTITY THEFT: Subject to the Terms of this insurance and in the event the Insured Person’s identity is stolen, the Company will reimburse the Insured Person the Reasonable and Customary costs incurred by the Insured Person up to the amount shown in the BENEFIT SUMMARY for:

(1) re-filing loan or other credit applications that are rejected solely as a result of the Insured Person’s stolen identity

(2) notarization of legal documents

(3) long distance telephone calls, and postage incurred solely as a result of necessary reporting of the Insured Person’s stolen identity

(4) amending and/or rectifying records as a result of the Insured Person’s stolen identity

(5) up to three (3) credit reports obtained within one (1) year of the Insured Person’s knowledge of the stolen identity

(6) stop payment orders placed on missing or unauthorized checks as a result of the Insured Person’s stolen identity

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 Period of Coverage 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 Country of Residence is not the United States

(4) 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

(5) 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.

LOST LUGGAGE: Subject to Terms of this insurance and the limits set forth in the BENEFIT SUMMARY, the Company will reimburse the Insured Person for the cost of Lost Checked Luggage when such Luggage was permanently lost in transit by a Common Carrier during the Period of Coverage, subject to the following conditions:

(1) The Insured Person must submit to the Company a copy of the Common Carrier’s claim form and such other documentation as the Company may reasonably require proof that the Insured Person’s Luggage was permanently lost

(2) The Common Carrier must first reimburse the Insured Person the full amount that it is legally required to pay for Lost Checked Luggage, and proof of such reimbursement shall be provided to the Company by the Insured Person. Lost Luggage benefits under this insurance will be provided only if and to the extent the amount of the Insured Person’s loss suffered as a result of Lost Luggage exceeds any such reimbursement by the Common Carrier

NATURAL DISASTER: Subject to the Terms of this insurance and in the event of a Natural Disaster that occurred during the Period of Coverage, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY if the Insured Person is displaced from scheduled, paid accommodations due to an evacuation before a forecasted Natural Disaster or following a Natural Disaster. The evacuation must have been ordered and mandated by the governmental authorities having jurisdiction over the location of the predicted or actual Natural Disaster.

 

NATURAL DISASTER EVACUATION:

 

(1) Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and the CONDITIONS AND RESTRICTIONS subparagraph below, the Company will reimburse the Insured Person for the following transportation and accommodation costs, when the Company or Plan Administrator arranges such transportation and accommodations, and expenses incurred by the Insured Person arise out of or in connection with an evacuation due to a Natural Disaster that makes your Destination Country Uninhabitable during the Period of Coverage:

(a) air or ground transportation to the nearest safe location

(b) the cost of a one-way economy commercial airline ticket, if the Conditions and Restrictions are met below, to return the Insured Person to his/her Country of Residence following the Natural Disaster evacuation

(c) a maximum of three (3) days for reasonable and necessary lodging accommodations if the Insured Person is delayed in a safe location and unable to return to his/her Country of Residence.

 

CONDITIONS AND RESTRICTIONS: To be eligible for coverage for Natural Disaster Evacuation benefits, the Insured Person must be in compliance with all Terms of this insurance. Expenses for non-emergency transportation are the Insured Person’s sole responsibility. The Company will provide Natural Disaster Evacuation benefits only when all of the following conditions and restrictions are met:

(a) the Natural Disaster Evacuation must have been ordered and mandated by the recognized governmental authorities having jurisdiction over the location within the Insured Person’s Destination Country

(b) the Insured Person is unable to leave their Destination Country by normal means, including but not limited to changing an existing Common Carrier reservation to arrange for an earlier return due to the Natural Disaster

(c) the Insured Person is unable to obtain commercial transportation within the Destination Country to travel to the nearest safe location in a time period that would:

(i) avoid Imminent Bodily Harm

(ii) comply with the time allowed to leave the Destination Country pursuant to the orders of the recognized government of the Insured Person’s Destination Country

(iii) comply with the time allowed by officials of the Destination Country or the U.S. Embassy

(d) the Insured Person’s location in the Destination Country is deemed Uninhabitable by the Company

(e) the Insured Person must contact the Company as soon as reasonably possible after the Destination Country has issued an official disaster declaration

(f) Natural Disaster Evacuation is approved in advance by the Company.

By acceptance of this Certificate and request for Natural Disaster Evacuation benefits hereunder, the Insured Person understands, acknowledges and agrees that the timeliness, duration, occurrences during and outcome of an Natural Disaster 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 a Natural Disaster 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 Natural Disaster 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 Natural Disaster 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 Natural Disaster Evacuation and seek reimbursement thereafter for eligible costs associated with that subsequent Natural Disaster Evacuation.

 

NON-EMERGENCY MEDICAL EVACUATION:

 

(1) Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and the CONDITIONS AND RESTRICTIONS subparagraph below, the Company will reimburse the Insured Person for the following transportation costs, when the Company arranges such transportation, and expenses incurred by the Insured Person arising out of or in connection with a Non-emergency Medical Evacuation occurring while this Certificate is in effect and during the Period of Coverage:

(a) air transportation to a suitable airport nearest to the Hospital where the Insured Person will receive Treatment

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

 

CONDITIONS AND RESTRICTIONS: To be eligible for coverage for Non-emergency Medical Evacuation benefits, the Insured Person must be in compliance with all Terms of this insurance. The Company will provide Non-emergency Medical Evacuation benefits only when all of the following conditions and restrictions are met:

(a) the Insured Person is under the age of sixty-five (65)

(b) the Insured Person is Hospitalized outside of their Country of Residence and more than one hundred fifty (150) miles from home for a sudden and Unexpected medical condition, where Hospitalization is Medically Necessary

(c) Non-emergency Medical Evacuation is approved by the attending Physician who certifies the need for continued Hospitalization, and that the condition is not life-threatening

(d) Non-emergency Medical Evacuation is agreed to by the Insured Person or a Relative of the Insured Person

(e) Non-emergency Medical Evacuation is approved in advance and all arrangements are coordinated by the Company

(f) the condition, Illness, Injury or occurrence giving rise to the need for the Non-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 which would have caused a reasonably prudent person to seek medical attention

(ii) was not a Pre-existing Condition.

The Company will cover reimbursement for the above-described costs and expenses and will arrange Non-emergency Medical Evacuation to the qualified Hospital chosen by the Insured Person

In all cases the Company will make the necessary arrangements for the Non-emergency Medical Evacuation and will use its best efforts to arrange with independent, third-party contractors any Non-emergency Medical Evacuation within the least amount of time reasonably possible.

By acceptance of this Certificate and request for Non-emergency Medical Evacuation benefits hereunder, the Insured Person understands, acknowledges and agrees that the timeliness, duration, occurrences during, and outcome of a Non-emergency Medical Evacuation can be directly and indirectly affected by events and/or circumstances which 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 a Non-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 Non-emergency Medical Evacuation once it has been arranged by the Company will require the Insured Person to reimburse the Company for costs incurred for any Non-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 Non-emergency Medical Evacuation and seek reimbursement thereafter for eligible costs associated with that subsequent Non-emergency Medical Evacuation.

PERSONAL LIABILITY: Subject to the Terms of this insurance, including without limitation the various limits and sub-limits set forth in the BENEFIT SUMMARY and the conditions precedent and including the EXCLUSIONS provision, the Company will pay or reimburse an Insured Person for eligible court-entered judgments or Company approved settlements arising as a result of or in connection with the personal liability of the Insured Person incurred for acts, omissions and other occurrences covered under this insurance for losses or damages solely, directly and proximately caused by the negligent acts or omissions of the Insured Person during the Period of Coverage that result in the following:

(1) Injury to a Third Person occurring during the Period of Coverage, subject to the limits and sub-limits set forth in the BENEFIT SUMMARY

(2) Damage or loss to a Third Person’s personal property during the Period of Coverage, subject to the limits and sub-limits set forth in the BENEFIT SUMMARY.

As a condition precedent to the provision of any coverage or benefits to any Insured Person for Personal Liability, the Insured Person must notify the Company within five (5) days of any act, omission or occurrence that may create or impose any Personal Liability upon the Insured Person, and also within five (5) days of the initiation or receipt of service of any actual or threatened lawsuit, notice of claim, or proceeding filed or threatened to be filed against the Insured Person with respect to same. In addition, such notification(s) to the Company shall include a recitation of all circumstances, facts, and known or presumed causes of any loss or damage, and a description of the nature and approximate amount of any damages suffered by any Third Person. In addition, immediately upon receipt thereof the Insured Person shall provide to the Company copies of any pleadings, complaints, lawsuits, petitions, demand letters, notices, orders, summonses, subpoenas, opinions, briefs, motions, letters from opposing counsel, and any other documents or papers with respect to any such lawsuit or proceeding that are received or issued by, addressed to or from, remitted to or by, or served by or upon the Insured Person or his/her counsel. Any failure to so notify or provide papers or documents to the Company in strict accordance with the foregoing shall be deemed to be and will result in a forfeiture and waiver of any and all benefits, claims or coverage otherwise provided by this insurance under this provision.

 

PET RETURN: Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and if the Insured Person is Hospitalized for Treatment of an Illness or Injury during the Period of Coverage, the Company will reimburse the cost of a one-way economy commercial airline or ground transportation ticket to return a pet cat or dog to the airport within the Insured Person’s Country of Residence, provided that all of the following conditions are met:

(1) the Insured person is over the age of eighteen (18) and travelling alone with a pet cat or dog

(2) the Insured Person’s pet cat or dog will be left unattended for thirty-six (36) hours or longer.

 

POLITICAL EVACUATION AND REPATRIATION: If the United States Department of State, Bureau of Consular Affairs or similar government organization of the Insured Person’s Country of Residence orders the evacuation of all non-emergency government personnel from the Destination Country, due to political unrest, that becomes effective on or after the Insured Person’s date of arrival in the Destination Country, the Company will reimburse up to the amount shown in the BENEFIT SUMMARY for transportation to the nearest place of safety or for repatriation to the Insured Person’s Country of Residence provided that all of the following conditions are met:

(1) the Insured Person contacts the Company within ten (10) days of the United States Department of State, Bureau of Consular Affairs or similar government organization of the Insured Person’s Country of Residence issuing the evacuation order

(2) the evacuation order pertains to persons from the same Country of Residence as the Insured Person

(3) Political Evacuation and Repatriation is approved by the Company

In no event will the Company pay for a Political Evacuation if there is a Travel Warning or Emergency Travel Advisory in effect on or within six (6) months prior to the Insured Person’s date of arrival in the Destination Country. This coverage will provide the most appropriate and economical means of travel consistent under the circumstances of the Insured Person’s health and safety.

 

REMOTE TRANSPORTATION:

 

(1) Subject to the Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the CONDITIONS AND RESTRICTIONS subparagraph below, the Company will reimburse the Insured Person for the following expenses incurred by the Insured Person arising out of or in connection with a Remote Transportation expenses occurring while this Certificate is in effect:

(a) direct costs and other reasonable and customary expenses arising out of travel to the nearest Qualified Facility where the Insured Person will receive Treatment

(b) accommodation Charges with respect to the Insured Person’s transportation to the Qualified Facility.

 

 

CONDITIONS AND RESTRICTIONS: To be eligible for coverage for Remote Transportation benefits the Insured Person must be in compliance with all Terms of this insurance. The Company will provide Remote Transportation benefits only when the condition, Illness, Injury or occurrence giving rise to the Remote Transportation is covered under the Terms of this insurance. The Company will provide Remote Transportation benefits only when all of the following conditions are met:

(a) if, after the Insured Person receives the first Treatment required to stabilize or diagnose the medical situation in a Hospital or a clinic, the Insured Person’s condition is still considered to be:

(i) life-threatening by the treating Physician

(ii) a critical medical situation which is not necessarily immediately life-threatening, but is severe enough to result in death or a permanent disability if not treated right away

(iii) a critical medical situation for which no official diagnosis can be obtained at the current Facility

(b) Remote Transportation is recommended by the attending Physician who certifies to the matters in subparagraphs (2)(a)(i) thru (iii), above

(c) Remote Transportation is agreed to by the Insured Person or a Relative of the Insured Person

(d) Remote Transportation is approved in advance by the Company

(e) the severity of the critical medical situation, the absence of a Qualified Facility, and the necessity of the Remote Transportation must be confirmed by both the local treating Physician and the Company.

 

RETURN OF MINOR CHILDREN: Subject to the Terms of this insurance, in the event the Insured Person is Hospitalized for a covered Injury or Illness as an Inpatient or dies during the Period of Coverage and at the time of such Hospitalization the Insured Person was traveling alone with a Child, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY for the cost of a one-way economy commercial airline ticket to return the Child to his/her Country of Residence, including such economy commercial airline ticket cost for a chaperone if necessary and required by the airline for the safety of the Child, subject to the following conditions and limitations:

(1) The Insured Person must be outside the Country of Residence at the time of the Hospitalization as an Inpatient

(2) The return of the Child must occur during the Insured Person’s Hospitalization

(3) Reimbursable costs are only for a one-way economy commercial airline ticket from the International airport nearest to the Child at the time of the Insured Person’s Hospitalization to the International airport nearest to the Child’s Country of Residence

(4) All travel and transportation arrangements for the Child must be approved in advance by the Company in order to be eligible for coverage under this insurance

(5) The Company will deduct from the return transportation benefits payable hereunder the value, if any, of the unused commercial airline return ticket(s) possessed by or for the benefit of the Child at the time of the Insured Person’s Hospitalization. The Insured Person and/or the Child must first attempt to receive credit for or deduct toward the costs of the return trip.

The Company will not provide any benefits, reimbursements or coverages for any costs or expenses incurred by the Insured Person and/or by the Child for a return trip, if any, to the original location of the Child at the time of the Hospitalization.

RETURN OF MORTAL REMAINS: In the event of the death of the Insured Person during the Period of Coverage 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.

 

SMALL PET COMMON AIR CARRIER ACCIDENTAL DEATH BENEFIT: Subject to the Terms of this insurance, in the event of the Unexpected death of a pet cat or dog, up to thirty (30) pounds in weight, travelling with a covered Insured Person on a common air carrier, the Company will pay to the Insured Person up to the amount shown in the BENEFIT SUMMARY. This benefit applies only to the Insured Person’s originating flight from his Country of Residence and returning flight to his Country of Residence, and the pet must be checked in with the air carrier, whether traveling in the airplane cabin with the Insured Person or in the cargo/baggage area of the airplane.

 

 

SUPPLEMENTAL ACCIDENT BENEFIT: In the event of an Accident which gives rise to benefits covered under the Terms of this insurance, as a supplemental benefit the Company will also reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY related to the Treatment of an Injury resulting from such Accident, before applying any Deductible.

 

 

TRIP INTERRUPTION: Subject to the Terms of this insurance and in the event of the Unexpected death of a Relative of the Insured Person, or in the event the Insured Person’s trip or travel plans must be cancelled or interrupted as a result of a break-in or substantial destruction due to a fire or Natural Disaster of the Insured Person’s principal residence in his/her Country of Residence, the Company will reimburse the Insured Person’s actual expense up to the amount shown in the BENEFIT SUMMARY for the costs of a one-way commercial airline or ground transportation ticket of the same class as the unused travel ticket to transport the Insured Person from the International airport nearest to where the Insured Person was located at the time of learning of such death or destruction to the International airport nearest to (1) the location of the Relative’s funeral or place of burial, or (2) the Insured Person’s destroyed principal residence; subject to the following conditions and limitations:

(1) The Insured Person must be outside of his/her Country of Residence at the time of the Unexpected death of the Relative or the substantial destruction of the principal residence

(2) The Unexpected death of the Relative or the substantial destruction of the residence must have occurred during the Period of Coverage and was not caused by, due to, or a result of negligence or willful misconduct by the Insured Person

(3) The Company will deduct from any Trip Interruption benefits payable hereunder the value of any unused, return tickets held by the Insured Person at the time of the event. The Insured Person must promptly undertake all necessary actions to apply for and receive credit for any unused tickets.

The Company will not provide any benefits, reimbursements or coverages for any of the costs or expenses incurred by the Insured Person for a return trip, if any, to the location of the Insured Person at the time of learning of such death or destruction

 

                                                                                                EXCLUSIONS

 

Except as expressly provided for in the BENEFIT SUMMARY, all Charges, costs, expenses and/or claims incurred by the Insured Person, and any claim for death or dismemberment benefits, 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: 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, death and dismemberment, 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 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) 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

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

(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).

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.

 

2) TERRORISM: The Company shall not be liable for and will not provide coverage or benefits in excess of the amount shown in the BENEFIT SUMMARY 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:

(a) the Insured Person’s active and voluntary planning or coordination of or participation in any act of Terrorism

(b) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning or Emergency Travel Advisory 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

(c) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning or Emergency Travel Advisory 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.

 

 

3) PRE-EXISTING CONDITIONS: Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance.

 

 

4) 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.

 

 

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

 

 

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

 

 

 

 

7) Charges for any Treatment or supplies that are:

(a) not incurred, obtained or received by an Insured Person during the Period of Coverage

(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 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

 

 

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

 

(9) 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

 

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

 

(11) 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

 

(12) 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

 

(13) Charges incurred for Custodial Care

 

 

(14) 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

 

(15) 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

 

(16) 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)

 

(17) 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

 

(18) elective Surgery or Treatment of any kind

 

(19) 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

 

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

 

(21) 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

 

(22) 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

 

(23) 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

 

(24) 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

 

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

 

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

 

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

 

(28) 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

 

(29) 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

 

(30) 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

 

(31) 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

 

(32) 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

 

(33) any willfully Self-inflicted Injury or Illness

 

(34) any sexually transmitted or venereal disease

 

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

 

 

(36) 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

 

(37) any Substance Abuse

 

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

 

(39) orthoptics, visual therapy or visual eye training

 

(40) 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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

(48) 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

 

(49) 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, except as otherwise expressly provided for hereunder

 

(50) 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

 

(51) 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

 

(52) Charges incurred in the Insured Person’s Country of Residence, except as otherwise expressly provided for in this insurance

 

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

 

(54) 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 United States Food and Drug Administration or which are considered “off-label” drug use; and for drugs or medicines not prescribed by a Physician

 

(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 and all costs related to or arising from or in connection with all trips to the Destination Country undertaken for the purpose of securing medical Treatment or supplies

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

 

(58) Wear and tear of teeth due to cavities and chewing or biting down on hard objects, such as but not limited to pencils, ice cubes, nuts, popcorn, and hard candies

 

(59) Dental Injury without associated face, skull, neck and/or jaws Injury or that can be evaluated and Treated in a dental office

 

(60) Dental Treatment for services which provide oral care maintenance including tooth repair by fillings, root canals, tooth removal and x-rays

 

 

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

 

(62) Charges incurred for massage therapy

 

(63) Charges incurred for Personal Liability legal fees or out-of-pocket costs associated and/or related to the determination and/or settlement of a legal liability

 

(64) Accidental Death or Dismemberment when the Insured Person’s death or dismemberment is caused directly or indirectly by, results from, or where there is a contribution from, any of the following:

(a) bodily or mental infirmity, Illness or disease

(b) infection, other than infection occurring simultaneously with, and as a direct result of, the accidental Injury.

 

 

                                                                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.

 

 

                                                                                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.

In addition, in order to qualify for the higher coverage limit specified in the BENEFIT SUMMARY, a United States citizen with a Primary Health Plan must meet the following requirements:

(i) the Insured Person must be a United States citizen

(ii) the Insured Person must have a Primary Health Plan

(iii) the Primary Health Plan must have been in effect prior to the Effective Date of Coverage and must remain in force during the entire Period of Coverage

(iv) the Pre-existing Condition must be covered under the Primary Health Plan.

 

If these requirements cannot be substantiated at the time of claim, the benefits under this provision will be limited to the amount shown in the BENEFIT SUMMARY for Insured Persons without a Primary Health Plan.

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

 

Non-United States citizens:

• Age 69 and under:

• Maximum Limit: $1,000,000

 

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-Existing Condition

 

Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance except and unless the Charges resulted directly from an Acute Onset of Pre-existing Condition, in which case the Charges will be covered only according to the Terms of the ACUTE ONSET OF PRE-EXISTING CONDITIONS provision.

 

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

 

 

                                                UNITED STATES PREFERRED PROVIDER ORGANIZATION (PPO):

 

 

SPECIAL BENEFITS:

 

If Treatment or supplies eligible for coverage under this insurance are received directly from the Company’s approved list of independent Preferred Provider Organization (PPO) providers while the Insured Person is in the United States, the Company will adjust the Deductible and/or Coinsurance applicable to such claims according to the amount shown in the BENEFIT SUMMARY. 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.

 

 

PPO INFORMATION:

 

The Company, through the Plan Administrator, endeavors to maintain a contractual arrangement with one (1) or more independent Preferred Provider Organizations (PPO) that has established and maintains a network of United States-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 providers 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 perform any of the following:

 

 

(a) approve Applications or enrollments for initial, renewal or reinstated coverage under this insurance plan or accept Premium payments

 

(b) accept risks for or on behalf of the Company

 

(c) act for, speak for or bind the Company or the Plan Administrator in any way

 

(d) 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

 

(e) determine Pre-certification, coverage eligibility or 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 Deductible, Coinsurance and benefit reduction, 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 an Insured Person may visit the Plan Administrator’s website at www.imglobal.com/member to obtain such information.

 

 

PPO Link:- https://us1.welcometouhc.com/

 

                                                                                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.