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, Child and/or Grandchild

(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 habitual residency  in the Destination Country

Once the Insured Person and/or Spouse reaches the ages of seventy (70) and eighty (80) and at the time of their renewal,

the Period of Coverage limit will be reflective of their new age range as listed in the BENEFIT SUMMARY

 

TERMINATION OF COVERAGE FOR INSURED PERSONS

Coverage and benefits for the Insured Person under this insurance will terminate effective at 12:01 AM EST on the earliest of the following dates:

(a) the date the Master Policy is terminated pursuant to the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF MASTER POLICY provision

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

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

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

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

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

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

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

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

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

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

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

DEFINITIONS

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

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

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

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

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

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

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

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

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

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

(a) the termination date specified in the Declaration

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Educational or Rehabilitative Care: Care for restoration (by education or training) of a person’s ability to function in a normal or near normal manner following an Illness or Injury. This type of care includes, but is not limited to job training, counseling, vocational or occupational therapy, and speech therapy.

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

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

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

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

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

EST: United States Eastern Standard Time.

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

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

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

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

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

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

 

Ground level: The lowest point at the bottom of the mountain

 

Habitual residence; Habitual residency: The country in which the insured person resides or usual place of abode and any country wo which the insured person pays income taxes based upon employment in that time of purchase.In the event there is one 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 persons as their country of residence on the application.

 

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

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

Home Health Care Agency: A public or private agency or one of its subdivisions, which operates pursuant to law; and is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation and Treatment prescribed by a Physician.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stacked Insurance: Purchasing the same or like insurance product through the company for the same area of coverage for the same or similar coverage period, and for the same coverage intent to increase a claims payout.

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

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

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

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

(a) that occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent medical care

(b) that occurs after the Effective Date

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

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

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

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

Surgery; Surgical Procedure: An invasive diagnostic or surgical procedure, or the Treatment of Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.

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

Unexpected: Sudden, unintentional, not expected and unforeseen.

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

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

Affected Area(s): Any and all countries states, provinces, territories, cities or other areas experiencing ongoing transmissions of an Epidemic, Pandemic or other disease outbreak, or Natural Disaster.

Against Medical Advice; Discharge Against Medical Advice: Against Medical Advice, or AMA, sometimes known as DAMA, Discharge Against Medical Advice is a term used with a patient who checks himself or herself out of a hospital against the advice of their Treating Physician.

Authorization for Release of Medical Information: A written authorization by the insured person for health providers to release medical records and information regarding their past and current Treatment.

Emergency Use Authorization(EUA): A temporary authorization issued by the U.S. Food and Drug Administration(FDA) to allow the use of unapproved medical product, service, a surgery or Surgical Procedure, prescription medication, drug, biological product,  Durable Medical Equipment (DME) or device; or device or by allowing an otherwise unapproved use or application of an approved medical product, service, surgery or surgical procedure, prescription medication, drug, biological product, Durable Medical Equipment(DME) or device.

Epidemic: The occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time.

 

BENEFIT SUMMARY

Coverage Limit / Maximum Amount for Eligible Medical Expenses
Period of Coverage	Five (5) days up to twelve (12) months
Benefit Period  • Charges incurred in the United States are not eligible for coverage during the Benefit Period  • Refer to the BENEFIT PERIOD provision for further details and requirements	3 months
Period of Coverage limit As indicated on the Declaration	•        Through age 64: $50,000, $100,000, $500,000 or $1,000,000 •        Ages 65 to 69: $50,000 or $100,000 ·         Ages 70 to 79: $50,000 ·         Ages 80 and older: $10,000
Area of Coverage	Worldwide excluding the Insured Person’s Country of Residence and the United States
Deductible for Eligible Medical Expenses
Deductible	$0, $100, $250, $500, $1,000, or $2,500 per Insured Person, as indicated on the Declaration
Coinsurance for Eligible Medical Expenses
Coinsurance           •  In addition to Deductible	Plan pays 100%  Insured pays 0%
Out of Pocket Maximum	$0
Pre-certification
• Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met. • Emergency 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:  • Up to the Period of Coverage limit  • 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:  • Up to the Period of Coverage limit or $1,000,000 (whichever is lower)  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	Coinsurance
Eligible Medical Expenses	100%
Physician Visits / Services	100%
Urgent Care Center • Not subject to Deductible • Copayment: $25  • Copayment is not applicable if the Declaration     states a $0 Deductible	100%
Walk-in Clinic • Not subject to Deductible • Copayment $15  • Copayment is not applicable if the Declaration states a $0 Deductible	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	Coinsurance
	Hospital Emergency Room: United States	100%
	Hospital Emergency Room: International	100%
	Hospitalization / Room & Board • Average semi-private room rate  • Includes nursing, miscellaneous and Ancillary services	100%
	Intensive Care	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%
	Outpatient Surgical / Hospital Facility	100%
	Laboratory	100%
	Radiology / X-ray	100%
	Chemotherapy / Radiation Therapy	100%
	Pre-admission Testing	100%
	Surgery	100%
	Reconstructive Surgery • Surgery is incidental to and follows Surgery that was covered under the plan	100%
	Assistant Surgeon • Twenty percent (20%) of the primary surgeon’s eligible fee	100%
	Anesthesia	100%
	Durable Medical Equipment	100%
	Chiropractic Care • Medical order or Treatment plan required	100%
	Physical Therapy • Medical order or Treatment plan required	100%
	Extended Care Facility • Upon direct transfer from an acute care Hospital	100%
	Home Nursing Care • Provided by a Home Health Care Agency • Upon direct transfer from an acute care Hospital	100%
Prescription Drugs and Medication 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 The following Prescription Drugs and Medication Maximum Limit accumulates toward the plan Maximum Limit per Period of Coverage
Benefit
Prescription Drugs and Medication Obtained through Retail Pharmacy, Inpatient and Outpatient Surgery, Emergency Room and Outpatient Office Visits Dispensing maximum for Retail Pharmacy: 90 days per prescription		100% If the Certificate of Insurance Maximum Limit is $10,000, $50,000 or $100,000, the Prescription Drugs and Medications limit is up to the plan Maximum Limit If the Certificate of Insurance Maximum Limit is $500,000 or $1,000,000, the Prescription Drugs and Medications Maximum Limit is up to $250,000 per Period of Coverage
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		100%
Emergency Medical Evacuation  • Maximum Limit: $1,000,000  • Must be approved in advance and coordinated by the Company		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%
Interfacility Ambulance Transfer  • Transfer must be a result of an Inpatient Hospital admission		100%
Natural Disaster Evacuation  • Maximum Limit: $25,000  • Approved in advance by the Company		100%
Political Evacuation and Repatriation  • Maximum Limit: $100,000  • Must be approved in advance by the Company		100%
Remote Transportation  • Maximum Limit: $20,000  • Limit: $5,000 • Approved in advance by the Company		100%
Return of Minor Children  • Maximum Limit: $100,000  • Must be approved in advance by the Company		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%

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%
Dental Treatment  • Subject to Deductible and Coinsurance  • Limit: $300  (Unexpected pain or Treatment due to an Accident)	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%
Hospital Indemnity  • Overnight limit: $250 • Maximum nights: 10  • Outside Insured Person’s Country of Residence and the United States • Inpatient Hospitalization only	100%
Emergency Eye Examination  • Deductible per occurrence: $50 (plan Deductible waived)  • Limit: $150  • Loss or damage to prescription corrective lenses due to an Accident	100%
Identity Theft  • Limit: $500	100%
Lost Luggage  • Limit: $500   • Limit: $50 per item	100%
Natural Disaster  • Limit per day: $250  • Maximum days: 5	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	Coinsurance
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
Pet Return  • Limit: $1,000  • For a pet cat or dog travelling with the Insured Person	$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
Supplemental Accident Benefit  • Maximum Limit per covered Accident: $300	$100
Return Travel  • Limit: $10,000	$100
Incidental 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	Combined Maximum Limit: $50,000
Emergency Treatment While Traveling Through the United States  • Maximum consecutive days: 14 (in addition to the combined Maximum Limit)  • Must be Pre-certified and coordinated by the Company  • Refer to the EMERGENCY TREATMENT WHILE TRAVELING THROUGH THE UNITED STATES provision for further details and requirements	100%
Emergency Medical Evacuation to the United States and Associated Treatment  • Maximum consecutive days: 14 (in addition to the combined Maximum Limit)  • Must be Pre-certified and coordinated by the Company  • Refer to the EMERGENCY MEDICAL EVACUATION TO THE UNITED STATES AND ASSOCIATED TREATMENT provision for further details and requirements	100%
Emergency Treatment During Incidental Trip to Country of Residence  • Maximum consecutive days: 14  (in addition to the combined Maximum Limit)  • Must be Pre-certified and coordinated by the Company  • Refer to the EMERGENCY TREATMENT DURING INCIDENTAL TRIP TO COUNTRY OF RESIDENCE provision for further details and requirements	100%

EXCLUSIONS

I. 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) ECONOMIC SANCTIONS: The Company will not cover any person as an Insured Person if such cover would result in the Company being exposed to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws, or regulations of the European Union, United Kingdom or the United States of America.

(2) 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, insurgency, 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.

 

(3) 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.

(4) PRE-EXISTING CONDITIONS: 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.

(5) 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.

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

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

(8)   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 their 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 received prior to coverage under this insurance or that is excluded from coverage or which is otherwise not covered under this insurance

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

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

(10) Charges incurred due to fluctuations in exchange rates or for any bank charges the Insured Person incurs when a check, bank transfer, or payment is received from the Company

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

 

(12) 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, drugs, recombinant adeno-associated virus vector-based gene therapy, and other Medication Treatments associated with diagnoses related to genetic testing and discovery, 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

(13) 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

(14) Charges incurred for Custodial Care

(15) 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

(16) 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

(17) 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)

(18) 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

(19) Elective Surgery or Treatment of any kind

(20) 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

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

(22) 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 but not limited to the National Collegiate Athletic Association, any other collegiate sanctioning or Governing Body or the International Olympic Committee

(23) 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; and windsurfing

(24) 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; big game hunting; 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 or trekking above elevation of 4500 meters; parkour; piloting a commercial or non- commercial aircraft; powerbocking; scuba diving or sub aqua pursuits below a depth of 40 meters; snowmobile racing; truck racing; whitewater kayaking or whitewater rafting Class VI and higher difficulty; and wingsuit flying

(25) 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

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

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

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

(29) 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

(30) 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

(31) 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

(32) 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

 

(33) 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

(34) any willfully Self-inflicted Injury or Illness

(35) any sexually transmitted or venereal disease

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

ARC Syndrome, AIDS

(37) 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

(38) any Substance Abuse

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

(40) orthoptics, visual therapy or visual eye training

(41) 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

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

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

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

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

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

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

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

(49) any Illness or Injury incurred in the Destination Country, Affected Area or Country of Residence as a result of a Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster, that may affect an Insured Person’s health, unless coverage is expressly provided under the PUBLIC HEALTH EMERGENCY provision of this insurance

This exclusion DOES NOT apply to Charges resulting from COVID-19/SARS-CoV-2.

(50) 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

(51) 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

(52) 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

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

(54) Charges incurred within the United States, except as otherwise expressly provided for hereunder

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

(56) 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 (FDA) or which are considered “off-label” drug use; and for drugs or medicines not prescribed by a Physician

(57) any Treatment for an Illness or Injury requiring an unapproved U.S. Food and Drug Administration (FDA) medical product, services, Surgery, Surgical Procedure, prescription medication, drug, biological product, Durable Medical Equipment (DME) or device when an Emergency Use Authorization (EUA) is in place issued by the U.S. Food and Drug Administration (FDA)

(58) Charges incurred at a Hospital or Facility when the Insured Person checks themself out Against Medical Advice of their Physician and leaves before reaching a Medically Necessary specified endpoint of Treatment

 

(59) Charges incurred for the Worsening of an Illness or Injury after the Insured Person left a Hospital or Facility Against Medical Advice or was a Discharge Against Medical Advice

(60) 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

(61) 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

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

(63) 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

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

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

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

(67) Charges incurred for massage therapy

(68) 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.

 

The Company, through the Plan Administrator, endeavors to maintain a contractual arrangement with an independent Preferred Provider Organization (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:

• approve Applications or enrollments for initial, renewal or reinstated coverage under this insurance plan or to accept Premium payments,
• accept risks for or on behalf of the Company,
• act for, speak for, or bind the Company or the Plan Administrator in any way,
• 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
• 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 that applicable 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://www.imglobal.com to obtain such information.

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 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 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 thirty (30) days prior written notice to the Assured and the Insured Person (Notice of Amendment). The Notice of Amendment shall include a complete description of the changes, additions, and/or deletions to be made, the Effective Date thereof (the Change Date), and notice of the Insured Person’s cancellation rights 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.

CANCEL

CANCELLATION BY INSURED PERSON: The Insured Person shall have three (3) days from the Initial Effective Date, as defined herein, (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 via the MyIMG customer portal (www.imglobal.com/member) or 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 Insured person may request cancellation via the MyIMG customer portal or by sending a written request to the Company by email, mail or fax. However, the following conditions apply for Premium refund:

(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, regardless of the reason for cancellation; and

(ii)    any refund amount that is less than the cancellation fee is non-refundable; and

(iii)   only Premium covering time periods after the requested cancellation date are refundable.

 

CLAIMS

(1)   CLAIMS NOTIFICATION: All claims and related claim information should be filed with the Company through the Plan Administrator via the MyIMG customer portal atwww.imglobal.com/member within the timely filing requirements outlined below. Alternatively, claims can be filed at the contact information below:

International Medical Group Attn: Claims Department PO Box 240429

Apple Valley, MN 55124 USA

Proof of Claim: When the Insured Person receives Treatment or the Company receives notice of a claim for benefits under this insurance, the Insured Person shall submit an International Medical Group (IMG) Claim Form as a necessary component of the Proof of Claim. An IMG Claim Form may be completed online via the MyIMG customer portal atwww.imglobal.com/member or obtained by contacting the Company.

(a)  A Proof of Claim shall not be effective and will not satisfy the Terms of this insurance unless it includes all the following:

(i)  a duly completed, timely submitted and signed IMG Claim Form for each new Illness, diagnosis or Injury unless the Company waives such requirement in writing

(ii) an Authorization for Release of Medical Information when specifically requested by IMG

(iii) all original Universal Billing Forms, Superbill and statements of service rendered from Physicians, Hospitals, and other healthcare or medical service providers involved with respect to the claim

(iv) all original receipts for any costs, prescription medications, fees or expenses that have been incurred or paid by, or on behalf of, the Insured Person with respect to the claims, 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 service (applicable procedure codes), and diagnosis codes must be included on the receipts.

(v) If the claims are submitted electronically, copies of the above items are acceptable; however, the Company reserves the right to request the original documents.

(b)TIMELY FILING REQUIREMENTS: 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 any of the following:

(i) IMG’s receipt of an incomplete Proof of Claim

(ii) failure to submit any Proof of Claim

(iii) Insured Person’s, Physician’s or Hospital’s failure to submit a timely Proof of Claim

(c) The Company may require the Insured Person to sign an Authorization for Release of Medical Information to request medical records on their behalf or supply us with additional documentation if we are unable to make a benefit determination based on the submitted Proof of Claim. The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have sixty (60) days from the date of the request to submit the requested information. If the information is not received within the designated time period, previously submitted and subsequent claims will be denied.

(2)   APPEALING A CLAIM: In the event the Company denies all or part of a claim, the Insured Person shall have ninety (90) 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

PO Box 240429

Apple Valley, MN 55124 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.

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 programs, 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”) that 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.

The Company reserves the right to cancel any and all coverage if it is determined an Insured Person has Stacked Insurance.

PRE-CERTIFICATION REQUIREMENTS: Pre-certification is a general determination of Medical Necessity only, and all such determinations are made by the Company (acting through its authorized agents and representatives) in reliance and based upon the completeness and accuracy of the information provided by the Insured Person and/or their Relatives, guardians and/or healthcare providers at the time of Pre-certification. The Company reserves the right to challenge, dispute and/or revoke a prior determination of Medical Necessity based upon subsequent information obtained. Pre-certification is not an assurance, authorization, preauthorization, or verification of Treatment or coverage, a verification of benefits, or a guarantee of payment. The fact that Treatment or supplies are Pre-certified by the Company does not guarantee the payment of benefits, the availability of coverage, or the amount of or eligibility for benefits. The Company’s consideration and determination of a Pre-certification request, as well as any subsequent review or adjudication of all medical claims submitted in connection therewith, shall remain subject to all of the Terms of this insurance, including exclusions for Pre- existing Conditions and other designated exclusions, benefit limitations and sub-limitations, and the requirement that claims be Usual, Reasonable and Customary. Any consideration or determination of a Pre-certification request shall not be deemed or considered as the Company’s approval, authorization or ratification of, recommendation for, or consent to any diagnosis or proposed course of Treatment. Neither the Company nor the Plan Administrator (nor anyone acting on their respective behalves) has any authority or obligation to select Physicians, Hospitals, or other healthcare providers for the Insured Person, or to make any diagnosis or medical Treatment decisions on behalf of the Insured Person, and all such decisions must be made solely and exclusively by the Insured Person and/or their family members or guardians, Treating Physicians and other healthcare providers. If the Insured Person and their healthcare providers comply with the Pre- certification requirements of the Master Policy and this Certificate, and the Treatment or supplies are Pre-certified as Medically Necessary, the Company will reimburse the Insured Person for Eligible Medical Expenses up to the amount shown in the BENEFIT SUMMARY incurred in relation thereto, subject to all Terms of this insurance. Eligibility for and payment of benefits are subject to all of the Terms of this insurance.

(1) SPECIFIC REQUIREMENTS: The following must always be Pre-certified for Medical Necessity by the Company through the Plan Administrator before admission or receiving the Treatments and/or supplies:

(a) Chemotherapy

(b) Extended Care Facility

(c) Home Nursing Care

(d) Inpatient Hospitalization

(e) Interfacility Ambulance Transfer

(f) Radiation Therapy

(g) Surgery or Surgical procedure.

(2) GENERAL REQUIREMENTS: To comply with the Pre-certification requirements of this insurance for the Treatments and/or supplies or services listed in the SPECIFIC REQUIREMENTS provision, above, the Insured Person or their Physician or healthcare provider must perform all of the following:

(a) contact the Company through the Plan Administrator at the contact information below and on the Insured Person's ID card as soon as possible and before the Treatment or supply is to be obtained.

Inside the United States: +1.800.628.4664

Outside the United States: +1.317.655.4500 (Collect if necessary) E-mail: precertification@imglobal.com

Website:www.imglobal.com/member/precertification

(b) comply with the instructions of the Company and submit any information or documents required by the Company

(c) notify all Physicians, Hospitals and other healthcare providers that this insurance contains Pre-certification requirements and ask them to fully cooperate with the Company.

(3)  LOSS OF COVERAGE / BENEFITS FOR NON-COMPLIANCE OF PRE-CERTIFICATION REQUIREMENTS:  If the

Insured Person or their healthcare providers do not comply with the Pre-certification requirements for the Treatment or supplies identified in the SPECIFIC REQUIREMENTS subparagraphs above, or if such Treatment or supplies are not Pre- certified:

 

(a) Eligible Medical Expenses incurred with respect to said Treatment and/or supplies will be reduced by the amount shown in the BENEFIT SUMMARY

(b) the Deductible will be subtracted from the remaining amount

(c) Coinsurance will be applied.

(4) EMERGENCY PRE-CERTIFICATION: In the event of an Emergency Hospital admission, Pre-certification must be completed within forty-eight (48) hours after the admission, or as soon as is reasonably possible.

(5) CONCURRENT REVIEW: For Inpatient Treatment of any kind, the Company will Pre-certify a limited number of days of confinement based upon the disclosed medical condition. Thereafter, Pre-certification must again be requested and approved if additional days of Inpatient Treatment are necessary.

(6) APPEAL PROCESS: If the Insured Person disagrees with a Pre-certification decision of the Company, the Insured Person may in writing ask the Company to reconsider the decision and may supply additional documentation to support the appeal. The Company may reconsider its decision based on review of the additional documentation and facts, if any. The Company will advise the Insured Person of its decision within a reasonable time frame following receipt of additional documentation and facts.

The appeal must be sent to:

Phone: +1.317.655.4500, Option #2

Fax: +1.317.833.1990: ATTN: Pre-certification–- Appeals Email: precertification@imglobal.com