Patriot Exchange Program - Basic With Addon
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:
- be an active participant in a study and exchange program (i.e.; student visa, exchange visitor visa, visitor visa) the Spouse of the participant, or a Dependent traveling with the participant and residing outside his/her Home Country for the purpose of pursing international educational activities for a temporary period of time; and
- on the Effective Date, be physically and legally residing in the Destination Country with the intent to reside there for at least thirty (30) days
- complete and sign an Application as the Insured Person (or be listed thereon by proxy as an applicant and proposed Insured Person), and/or as the Insured Person’s spouse and/or Child; and
- pay the required Premium on or before the Effective Date of Coverage; and
- receive written acceptance of his/her Application or renewal from the Company; and
- be at least thirty one (31) days old but not yet sixty-five (65) years old; and
- not be Hospitalized or Disabled on the Initial Effective Date; and
- not be HIV+ on the Initial Effective Date.
Subject to the Terms of this insurance and the insurance plan shown in the Declaration, the following insurance plans are available to the Insured Person while outside his/her Home Country and offer the following benefits and coverage arising out of Injury or Illness incurred while in the Host Country and the insurance plan shown in the Declaration is in effect:
|Period of Coverage||365 day Maximum Limit|
|Maximum Limit Per Lifetime||$5,000,000|
|Maximum Limit Per Illness or Injury||$50,000; $100,000; $250,000; or $500,000 as indicated in Declaration.|
|Area of Coverage||Worldwide; excluding Home Country|
|Deductible||$100 per Illness or Injury.|
|Emergency Room Deductible||An additional Deductible of $250 will be applied for each Emergency Room visit for Treatment of an Illness which does not result in inpatient status.|
|Treatment Period Maximum||60 days for Chronic Conditions.|
|Student Health Center||$5.00 copay per visit for Treatment of Eligible Medical Expenses; not subject to Deductible.|
|Pre-Existing Conditions||If condition existed within thirty-six (36) months prior to Effective Date, Charges are excluded until after twelve (12) months of coverage and then $500 Maximum Limit Per Period of Coverage and $50,000 Maximum Limit per lifetime.|
|Terrorism||$50,000 Maximum Limit per lifetime.|
|Sudden & Unexpected Reoccurrence of Pre-existing Condition||$5,000 Maximum Limit per lifetime for Eligible Medical Expenses; $25,000 Maximum Limit for Emergency Medical Evacuation.|
|The following benefits are subject to the Deductible and Coinsurance as described above and cannot exceed the Maximum Limit. When the Eligible Expense criteria are met, the benefit offered under the insurance plan shown in the Declaration shall be as follows:|
|Hospital Room & Board||Up to the average semi-private room rate, including nursing service.|
|Intensive Care Unit||Usual, Reasonable and Customary.|
|Physical Therapy||Usual, Reasonable and Customary; Outpatients are limited to 1 visit per day|
|Physician’s Visits||Usual, Reasonable and Customary; Limited to 1 visit per day unless for visit to a provider of a different medical/surgical specialty.|
|Eligible Medical Expenses||Usual, Reasonable and Customary.|
|Dental Treatment||Relief of sudden and unexpected pain to sound, natural teeth, including but not limited to fillings: $350 Maximum Limit.
Injury including jaw fracture: $500 Maximum Limit per Accident
|The following benefits are not subject to a Deductible, but cannot exceed the Maximum Limit. The benefits offered under the insurance plan shown in the Declaration shall be as follows:|
|Accidental Death & Dismemberment Benefit||Accidental Death Principal Sum: $25,000
Dismemberment: See Schedule in Accidental Death and Dismemberment Benefit section.
|Emergency Medical Evacuation||$50,000 Maximum Limit per lifetime. Must be approved in advance and coordinated by the Company.|
|Emergency Reunion||$15,000 Maximum Limit per lifetime. Must be approved in advance and coordinated by the Company.|
|Return of Mortal Remains||$25,000 Maximum Limit per Insured Person for return of the Insured Person’s Mortal Remains or ashes to their Home Country or $5,000 Maximum Limit per Insured Person for preparation, local burial or cremation of the Insured Person’s mortal remains at the place of death. Must be approved in advance and coordinated by the Company.|
|Political Evacuation and Repatriation||$10,000 Maximum Limit per lifetime. Must be approved in advance and coordinated by the Company.|
|Pre-certification||50% reduction of Eligible Medical Expenses if Pre-certification provisions are not met.|
|Incidental Trip Coverage||Up to 14 days.|
Except as expressly provided for in the Schedule of Benefits/Limits, all charges, costs, expenses and/or claims (collectively “Charges”) incurred by the Insured Person and any claim for death or dismemberment benefits 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 – Subject to the Terms of Section F.(5), above, and Section N.(2), below, the Company shall not be liable for and will not provide coverage or benefits for any claim or Charges incurred with respect to any Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising or incurred in connection with or as a result of any of the following acts or events (collectively, "Occurrences"):
- war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war;
- mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power;
- any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by violence of any type;
- martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege; and
- any use of radiological, chemical, nuclear or biological weapons or any other radiological, chemical, nuclear or biological events of any type (including in connection with an act of Terrorism).
Any claim, Charges, Illness, Injury or other consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether or not directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said Occurrences shall be deemed and considered to be consequences for which the Company shall not be liable under the Master Policy or this Certificate, except to the extent that the Insured Person shall prove that such claim, Charges, Illness, Injury or other consequence happened independently of the existence of such abnormal conditions and/or Occurrences.
(2) Terrorism – The Company shall not be liable for and will not provide coverage or benefits in excess of a $50,000 lifetime maximum benefit 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; and provided, further, the Company shall not be liable for and will not provide any coverage or benefits for any claim, charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with the following:
- the Insured Person's active and voluntary planning or coordination of or participation in any act of Terrorism; and/or
- any act of Terrorism that takes place in a location, post, area, territory or country for which the United States Department of State, Bureau of Consular Affairs issued a Travel Warning that was in effect on or within six (6) months prior to the Insured Person's date of arrival in said location, post, area, territory or country; and/or
- any act of Terrorism that takes place in a location, post, area, territory or country for which the United States Department of State, Bureau of Consular Affairs issues a Travel Warning that 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 arising or resulting directly or indirectly from or relating to any Pre-existing Condition, as herein defined, subject to the Terms of Section L., above; and
(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 complications of Newborns; and
(5) Charges for Treatment of Mental or Nervous Disorders; and
(6) Charges for any Treatment or supplies that are:
- not incurred, obtained or received by an Insured Person during the Period of Coverage; and/or
- not presented to the Company for payment by way of a complete Proof of Claim within ninety (90) days of the date such Charges are incurred; and/or
- not administered or ordered by a Physician; and/or
- not Medically Necessary; and/or
- provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable; and/or
- in excess of Usual, Reasonable, and Customary; and/or
- incurred by an Insured Person who was HIV + on or before the Effective Date of this insurance relating to or arising or resulting directly or indirectly from HIV, AIDS virus, AIDS related Illness, ARC Syndrome, AIDS and/or any other Illness arising or resulting from any complications or consequences of any of the foregoing conditions; whether or not the Insured Person had knowledge of his/her HIV status prior to the Effective Date, and whether or not the Charges are incurred in relation to or as a result of said status; and/or
- provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician; and/or
- performed or provided by a Relative of the Insured Person; and/or
- not expressly included as Eligible Medical Expenses as defined in Section F., above; and/or
- provided by a person who resides or has resided with the Insured Person or in the Insured Person's home; and/or
- required or recommended as a result of complications or consequences arising from or related to any Treatment, Illness, Injury, or supply excluded from coverage or which is otherwise not covered under this insurance; and
- for Congenital Disorders and conditions arising out of or resulting therefrom; and
(7) Charges incurred for telephone consultations except Telemedicine consultations through an established Telemedicine protocol system will be considered individually based on medical necessity and appropriateness as determined by the Company under the plan; and
(8) Charges incurred due to a failure to keep a scheduled appointment; and
(9) Charges incurred for Surgeries or Treatment or supplies which are:
- Investigational, Experimental, or for research purposes, and/or
- related to genetic medicine, genetic testing, surveillance testing and/or wellness screening procedures for genetically predisposed conditions indicated by genetic medicine or genetic testing, including, but not limited to amniocentesis, genetic screening, risk assessment, preventive and prophylactic surgeries recommended by genetic testing, and/or any procedures used to determine pre-disposition, provide genetic counseling, or administration of gene therapy; and
(10) Charges incurred while confined primarily to receive Custodial Care, Educational or Rehabilitative Care; and
(11) Charges incurred for any Surgery, Treatment or supplies relating to, arising from or in connection with, for, or as a result of:
- weight modification or any Inpatient, Outpatient, Surgical or other Treatment of obesity (including without limitation morbid obesity), including without limitation wiring of the teeth and all forms or procedures of bariatric Surgery by whatever name called, or reversal thereof, including without limitation intestinal bypass, gastric bypass, gastric banding, vertical banded gastroplasty, biliopancreatic diversion, duodenal switch, or stomach reduction or stapling; and/or
- modification of the physical body in order to change or improve or attempt to change or improve the physical appearance or psychological, mental or emotional well-being of the Insured Person (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof); and/or
- elective Surgery or Treatment of any kind; and/or
- cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and follows a Surgery which was covered under this insurance; and/or
- any Illness or Injury sustained while taking part in: Amateur Athletics, Professional Athletics, or other athletic activity that is sponsored or sanctioned by the National Collegiate Athletic Association (and/or any other collegiate sanctioning or governing body), or the International Olympic Committee, and adventure sports and activities, including, without limitation the following (including any combination or derivative of the following): abseiling; mountaineering activities where specialized climbing equipment, ropes or guides are normally or reasonably should have been used; athletic or sporting activities (except for activities that are non-contact, non-professional, and engaged in by You solely for recreational, entertainment or fitness purposes); aviation (except when travelling solely as a passenger in a commercial aircraft); motocross (MOTO-X); BMX; BASE jumping; bobsledding; bungee jumping; canyoning; caving; hang gliding; heli-skiing; high diving; hot air ballooning; inline skating; jet skiing; jungle zip lining; kiteboarding; kayaking; luge; mountain biking; parachuting; paragliding; parascending; rappelling; racing of any kind including without limitation by horse, motor or other vehicle (of any type) or motorcycle; rock climbing; any rodeo activity; ski jumping; sky diving; snow skiing except for recreational downhill and/or cross country snow skiing (provided that there is no coverage for any Illness of Injury sustained while skiing in violation of applicable laws, rules or regulations; away from prepared and marked in-bound territories; and/or against the advice of the local ski school or local authoritative body); snowboarding; snowmobiling; spelunking; surfing; trekking; whitewater rafting; windsurfing; wildlife safaris; and sub-aqua pursuits involving underwater breathing apparatus below a depth of 10 meters. Practice or training in preparation for any excluded activity which results in Illness or Injury will be considered as activity while taking part in such activity; and/or
- any Illness or Injury sustained while participating in any sporting, recreational or adventure activity where 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; and/or
- any Illness or Injury sustained while participating in any activity where such activity is undertaken in disregard of or against the recommendations, Treatment programs, or medical advice of a Physician or other healthcare provider; and/or
- any Injury or Illness sustained as a result of being under the influence of or due wholly or partly to the effects of alcohol, liquor, intoxicating substance, narcotics or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician but not for the Treatment of Substance Abuse; and/or
- any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician. For purposes of this exclusion, "vehicle" shall include motorized devices regardless of whether or not a driver or operator license is required (including watercraft and aircraft) and non-motorized bicycles and scooters for which no permit or license is required; and/or
- any willfully Self-inflicted Injury or Illness; and/or
- any sexually transmitted or venereal disease; and/or
- any testing for the following: HIV, seropositivity to the AIDS virus, AIDS related Illnesses, ARC Syndrome, AIDS; and/or
- any Illness or Injury resulting from or occurring during the commission of a violation of law by the Insured Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations; and/or
- any Substance Abuse; and/or
- speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy; and/or
- orthoptics, visual therapy or visual eye training; and/or
- any 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; provided, however, that claims for Treatment or supplies for the feet may be eligible for coverage under this insurance at the sole option of the Company and subject to all other
Terms of this insurance when related to:
- an Injury to the foot arising from an Accident covered hereunder; or
- an Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of Treatment; and/or
- hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician; and/or
- any sleep disorder, including without limitation sleep apnea; and/or
- any exercise program, whether or not prescribed or recommended by a Physician; and/or
- any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s); and/or
- any organ or tissue or other transplant or related services, Treatment or supplies; and/or
- any artificial or mechanical devices designed to replace human organs temporarily or permanently; and/or
- any efforts to keep a donor alive for a transplant procedure; and/or
(12) Charges incurred for any Treatment or supply that either promotes or prevents or attempts to promote or prevent conception or birth; including but not limited to: artificial insemination; oral contraceptives, Treatment for infertility or impotency; vasectomy or reversal of vasectomy; sterilization or reversal of sterilization; surrogacy or abortion; and
(13) Charges incurred for any Treatment or supply that either promotes, enhances or corrects or attempts to promote, enhance or correct impotency or sexual dysfunction; and
(14) Charges incurred for Dental Treatment;
(15) Charges incurred for eyeglasses, contact lenses, hearing aids, hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason; and
(16) Charges incurred for eye Surgery, such as but not limited to radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness, or astigmatism; and
(17) Charges incurred in the Insured Person's Home Country, except as expressly provided for in this insurance; and
(18) Charges incurred outside the Coverage Area as indicated in Section C. Schedule of Benefits/Limits; and
(19) Charges incurred for any immunizations and/or Routine Physical Exams; and
(20) Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance; and
(21) Any taxes, involuntary or forced contributions, assessments, charges, fees or surcharges imposed by any governmental agency or authority:
- arising out of or as a result of any Treatment or supplies received by the Insured Person, or
- based upon the Company's election hereunder, if any, to pay benefits directly to providers as an accommodation to the Insured Person, or
- for any other reason; and
(22) Charges or expenses incurred for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; drugs or medicines not approved by the U.S. Food and Drug Administration or which are considered "off-label" drug use; and for drugs or medicines not prescribed by a Physician.
(23) Charges and all costs related to or arising from or in connection with all trips to the Host Country undertaken for the purpose of securing medical Treatment or supplies; and
(24) Charges incurred for hospice care.
(25) 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:
- bodily or mental infirmity, illness or disease; or
- infection, other than infection occurring simultaneously with, and as a direct result of, the accidental injury.
Acute Pre-Ex Coverage
If condition existed within thirty-six (36) months prior to Effective Date, Charges are excluded until after twelve (12) months of coverage and then $500 Maximum Limit Per Period of Coverage and $50,000 Maximum Limit per lifetime.
Subject to the Terms of this insurance, including without limitation the Exclusions set forth in Section N., the Conditions and Restrictions set forth below and the applicable Deductible and Coinsurance and other limits and sub-limits as specified in the Schedule of Benefits/Limits set forth in Section C., above, inthe event the Insured Person suffers or experiences an Unexpected recurrence 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 US$5,000 (not to exceed $5,000 Lifetime Maximum) for Eligible Medical Expenses incurred during the Period of Coverage with respect to the Unexpected recurrence of the Pre-existing Condition.
Conditions and Restrictions - To be eligible for the foregoing limited coverage and benefits for an Unexpected recurrence of a Pre-existing Condition, the Insured Person must be a U.S. citizen and 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 Unexpected recurrence of the Pre-existing Condition:
- 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; and
- The Insured Person must not be traveling with the intent or purpose to seek or obtain Treatment for the Pre-existing Condition; and
- 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; and
- The Pre-existing Condition must have been stabilized for at least thirty (30) days prior to the Effective Date without change in Treatment; and
- The Insured Person must be traveling outside the Home Country.
The Company, through the Plan Administrator, endeavors to maintain a contractual arrangement with one or more independent Preferred Provider Organizations (PPO) that has established and maintains a network of U.S.-based Physicians, Hospitals and other healthcare and health service providers who are contracted separately and directly with the PPO and who may provide re-pricings, discounts or reduced charges for Treatment or supplies provided to the Insured Person. Neither the Company nor the Plan Administrator has any authority or control over the operations or business of the PPO, or over the operations or business of any provider within the independent PPO network. Neither the PPO nor provider within the PPO network nor any of their respective agents, employees or representatives has or shall have any power or authority whatsoever to act for or on behalf of the Company or the Plan Administrator in any respect, including without limitation no power or authority to: (i) approve Applications or enrollments for initial, renewal or reinstated coverage under this insurance plan or to accept Premium payments, (ii) accept risks for or on behalf of the Company, (iii) act for, speak for, or bind the Company or the Plan Administrator in any way, (iv) waive, alter or amend any of the Terms of the Master Policy or this Certificate or waive, release, compromise or settle any of the Company’s rights, remedies, or interests thereunder or hereunder, or (v) determine Pre-certification, eligibility for coverage, verification of benefits, or make any coverage, benefit or claim adjudications or decisions of any kind. It is not a requirement of this insurance that the Insured Person seek Treatment or supplies exclusively from a provider within the independent PPO network. However, the Insured Person’s use or non-use of the PPO network may affect the scope and extent of benefits available under this insurance, including without limitation any applicable 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 may visit the Plan Administrator’s website at http://myimglobal.com to obtain such information.
Subject to the Terms of the Termination of Master Policy and Termination of Coverage for Insured Persons sections, an Insured Person whose initial Period of Coverage is at least one (1) month can request coverage under this insurance plan to be renewed a minimum of five (5) days until reaching a maximum of forty-eight (48) 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 renewal Premium is paid when due and the Insured Person otherwise continues to meet the applicable eligibility requirements of the plan.
The Company’s commitment and the Insured Person’s ability to renew is also subject to termination upon thirty (30) days written notice to the other party prior to the expiration date of the then existing Period of Coverage. The Company reserves the right in its sole discretion to make changes, additions and/or deletions to the Terms of the Master Policy, this Certificate, renewals or replacements of either, and/or to the 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 as set forth below, and shall be sent first class mail, postage pre-paid, to the last known residence or mailing address of the Insured Person. Upon issuance of the Notice of Amendment, the Assured and/or the Insured Person shall have the right to request cancellation of this Certificate above, at any time prior to the Change Date; provided, however that cancellation under this section shall be at the option of the Insured Person, and coverage under this insurance shall terminate with effect from the cancellation date specified by the Insured Person (subject to the provisions of the Termination of Coverage for Insured Persons section. If the Insured Person does not elect to cancel this Certificate in accordance with the foregoing, the changes, additions and/or deletions as made by the Company and specified in said Notice of Amendment shall take effect as of the Change Date specified in the Company’s Notice, and this insurance shall thereafter continue in effect in accordance with its Terms, as so amended and modified.
The Insured Person shall have five (5) days from the Initial Effective Date of Coverage (the “Review Period”) to review the benefits, conditions, limitations, exclusions and all other Terms of the Master Policy as evidenced and outlined by this Certificate. If not completely satisfied, the Insured Person may request cancellation of this insurance retroactive to the Initial Effective Date of Coverage by sending a written request to the Company by mail or fax and received by the Company within the Review Period, thereby qualifying to receive a full refund of Premium paid. Upon effectuation of such cancellation and refund, neither the Company nor the Insured Person shall have any further rights, liabilities or obligations under this insurance.
After the Review Period, the following conditions apply if the Insured Persons wishes to cancel this insurance:
- If any claims have been filed with the Company, the Premium is fully earned and is non-refundable.
- If no claims have been filed with the Company,
- a cancellation fee of US$50.00 will be charged; and
- only full month premiums will be considered as refundable.
PROOF OF CLAIM - When the Company receives notice of a claim for benefits under this insurance from or on behalf of an Insured Person it will provide the Insured Person with Claimant's Statement and Authorization Forms ("Claim Forms") for filing Proof of Claim. The following items must be submitted by or on behalf of the Insured Person to be considered a complete Proof of Claim eligible for consideration of coverage under this insurance ("Proof of Claim"):
- a duly completed, timely submitted, and signed Claim Form and authorization for release of information; and
- all original itemized bills and statements of services rendered from all Physicians, Hospitals and other healthcare or medical service providers involved with respect to the claim; and
- all original receipts for any costs, fees or expenses that have been incurred or paid by or on behalf of the Insured Person with respect to the claim, including without limitation all original receipts for any cash and/or credit card payments. The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and supplier shall have ninety (90) days from the date a claim is incurred to submit a complete Proof of Claim, and the Company at its option may pend resolution and adjudication of submitted claims and/or may deny coverage: for Proofs of Claim submitted thereafter; or for incomplete Proofs of Claim; and/or for failure to submit a Proof of Claim; provided, however, that the Company at its option may waive the requirements of subsection B.(3)(a), above, regarding submission of a new Claim Form for subsequent claims incurred by an Insured Person relating to a continuing Illness, Injury or other medical condition for which a properly completed and signed Claim Form has previously been submitted and received.
APPEALING A CLAIM - In the event the Company denies all or part of a claim, the Insured Person shall have a reasonable opportunity to appeal the denial under which there will be a review of the claim and the determination. Insured Persons shall have sixty (60) days from the date that the notice of denial was mailed to the Insured Person's last known residence or mailing address within which to appeal the determination, and shall have the opportunity to submit written comments, documents, records, and other information relating to the claim. The Company's review will take into account all comments, documents, records, and other information submitted by the Insured Person relating to the claim, without regard to whether such information was submitted or considered in the initial claim determination. Insured Persons must file two (2) appeals of a claim denial prior to bringing any legal action under the contract of insurance. Upon receipt of a written appeal, the Company shall have an opportunity for further reasonable investigation and/or review as set forth in Section B.(22), and will respond in writing as soon as reasonably practicable, and in any event within ninety (90) days from receipt thereof.
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 applicable Deductible and Coinsurance, if any, and to the benefit limits and sub-limits 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 Section 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 Insured 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.