Atlas Essential International
Detail
Applicant Eligibility |
|
Minimum Age |
At least fourteen (14) days of age. |
Maximum Age |
80 and above. |
Period of Coverage |
maximum duration of twelve (12) months. |
Destination Country |
Traveling outside of Their Home Country. Also excluding restricted countries and US states given below. |
Restriction Details |
Restricted Countries |
The following countries can NEVER be listed as Destination: |
Iran |
The following country can NEVER be listed as Destination (Exception for U.S. Citizens) - U.S. Citizens must certify that they qualify for travel authorized under US Treasury's regulations and that they comply with the terms of such authorization |
Cuba |
The following countries are NOT available for selection at purchase as Destination: |
Belarus |
The following countries can NEVER be listed as Home Country: |
Cuba |
The following countries can NEVER be listed as Citizenship: |
Cuba |
U.S. Territories and Outlying Areas - United States Citizen / Home Country cannot list the following as Destination: |
Puerto Rico |
U.S. Territories and Outlying Areas - United States Citizen / Home Country can list the following countries as Destination: |
American Samoa |
Location at Purchase - The proposed applicant cannot be located in the following locations at the time of purchase: |
Australia |
Location at Purchase - The proposed applicant and the purchaser cannot be located in the following location at the time of purchase: |
Maryland (US State) |
Member Eligibility
U.S. citizens and non-U.S. citizens who are at least fourteen (14) days of age are eligible for coverage outside of their home countries, except as provided under home country coverage. U.S. citizens and residents are not eligible for coverage within the U.S, except as provided under incidental home country coverage or an eligible benefit period. Should you make a change to the location of your home country during the certificate period, you are no longer eligible for coverage in the new home country except as provided under home country coverage as of the date you establish the new home country.
Individuals ages sixty-five (65) to seventy-nine (79) as of the certificate effective date are subject to a $100,000 overall maximum limit or less. Individuals ages eighty (80) and over as of the certificate effective date are subject to a $10,000 overall maximum limit.
Certificate Effective & Termination Dates
Certificate Effective Date
Insurance hereunder is effective on the later of:
a. The moment we receive an application and correct premium if the application and payment is made online or by fax; or
b. 12:01am U.S. Eastern Time on the date we receive an application and correct premium if the application and payment is made by mail; or
c. The moment you depart from your home country; or
d. 12:01am U.S. Eastern Time on the date requested on the application if correct premium is received.
Certificate Termination Date
Insurance hereunder terminates on the earlier of:
a. 11:59pm U.S. Eastern Time on the last day of the period for which premium has been paid; or
b. 11:59pm U.S. Eastern Time on the date requested on the application; or
c. The moment of arrival upon your return to your home country (unless you have started a benefit period or are eligible for home country coverage).
Other Insurance
We shall not pay any claim if there is other insurance which would, or would but for the existence of this insurance, pay such claim. This insurance will apply with respect to expenses in excess of the amount paid or payable under such other insurance. We shall not pay any claim in respect to care, treatment, services or supplies furnished by any insurance, program or agency funded by any government.
Important Notice and Disclaimer Concerning the United States Patient Protection and Affordable Care Act
This insurance is not subject to, and does not provide certain insurance benefits required by the United States’ Patient Protection and Affordable Care Act (“PPACA”). PPACA requires certain U.S. citizens or U.S. residents to obtain PPACA compliant health insurance, or “minimum essential coverage.” PPACA also requires certain employers to offer PPACA compliant insurance coverage to their employees. Tax penalties may be imposed on U.S. residents or citizens who do not maintain minimum essential coverage, and on certain employers who do not offer PPACA compliant insurance coverage to their employees. In some cases, certain individuals may be deemed to have minimum essential coverage under PPACA even if their insurance coverage does not provide all of the benefits required by PPACA. You should consult your attorney or tax professional to determine whether this policy meets any obligations you may have under PPACA.
Benefit
BENEFITS
Plan Details
Overall Maximum Limit | Age 80 or older: $10,000. Age 65 to 79: $50,000 or $100,000. All others: $50,000, $100,000, $250,000, $500,000, or $1,000,000 |
Maximum per Injury / Illness | Age 80 or older: $10,000. Age 65 to 79: $50,000 or $100,000. All others: $50,000, $100,000, $250,000, $500,000, or $1,000,000 |
Deductibles | $0, $100, $250, $500, $1,000, $2,500, or $5,000 per certificate period |
Coinsurance | |
In-Network Payment | Within the PPO: We will pay 75% of eligible expenses after the deductible to the overall maximum limit |
Out-of-Network Payment | Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount. |
Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise. | |
Benefit | Limit |
Hospital Room and Board | Average semi-private room rate, including nursing services |
Intensive Care Unit | Up to the overall maximum limit |
Local Ambulance | Usual, reasonable and customary charges, only when covered illness or injury results in hospitalization as inpatient. |
Emergency Room Co-payment | Claims incurred in the U.S. You shall be responsible for a $200 co-payment for each use of emergency room for an illness unless you are admitted to the hospital. There will be no co-payment for emergency room treatment of an injury. Claims incurred outside the U.S. No co-payment |
Urgent Care Center Co-payment | Claims incurred in the U.S. For each visit, you shall be responsible for a $15 co-payment, after which coinsurance will apply. – Co-payment waived for members with a $0 deductible. – not subject to deductible Claims incurred outside the U.S. No co-payment |
Terrorism | Up to $50,000 lifetime maximum, eligible medical expenses only. |
Emergency Travel Benefits | Limit |
Emergency Medical Evacuation | Up to $500,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit |
Repatriation of Remains | Up to $25,000 lifetime maximum - not subject to deductible, coinsurance, or overall maximum limit |
Local Burial or Cremation | Up to $5,000 lifetime maximum - not subject to deductible or coinsurance |
Benefit Period
While the certificate is in effect, the benefit period does not apply. Upon termination of the certificate, including when you return to your home country, the benefit period applies for up to 90 days only to eligible medical expenses directly related to an injury or illness that was diagnosed or treated while the certificate was in effect. The benefit period begins on the first day of diagnosis or treatment of a covered injury or illness made while you are outside your home country. The benefit period applies whether ornot you return to your home country.
Incidental Home Country Coverage
You must have purchased three months of coverage for the Incidental Home Country Coverage to be in effect.
U.S. home country: For every three-month period during which you are covered, eligible medical expenses incurred in the U.S. are covered up to a maximum of 15 days.
Non-U.S. home country: For every three-month period during which you are covered, eligible medical expenses incurred in your home country are covered up to a maximum of 30 days.
Should you make a change to the location of your home country during the certificate period, you must notify us of such change within fifteen (15) days. Your new home country will govern the terms of any home country or incidental home country coverage.
Any benefit accrued under a single three-month period does not accumulate to another period. Failure to continue your international trip or your return to your home country for the sole purpose of obtaining treatment for an illness or injury that began while traveling shall void any incidental home country coverage.
Except for a benefit period, coverage provided under this Master Policy is for a maximum duration of 365 days for non-U.S. citizens or residents whose travel does not include the U.S. or U.S. Territories, and for all other members, the maximum certificate period is 364 days. Any extension of coverage is based upon the eligibility rules in force and is solely at our discretion.
Medical & Repatriation Expenses
Subject to the limits set forth in the Schedule of Benefits and Limits, and subject to the conditions and restrictions contained in this provision, we will pay the following expenses incurred while this insurance is in effect.
Medical Expenses
YOU ARE COVERED FOR:
- Charges made by a hospital for:
- Daily room and board and nursing services not to exceed the average semi-private room rate; and
- Daily room and board and nursing services in Intensive Care Unit; and
- Use of operating, treatment or recovery room; and
- Services and supplies which are routinely provided by the hospital to persons for use while inpatients; and
- Prescription drugs administered while inpatient for treatment of a covered injury or illness; and
- Emergency treatment of an injury, even if hospital confinement is not required; and
- Emergency treatment of an illness; subject to emergency room co-pay as outlined in the Schedule of Benefits and Limits. ER co-payment is waived when you are directly admitted to the hospital as inpatient for further treatment of that illness.
- Surgery at an outpatient surgical facility, including services and supplies.
- Charges made by a physician for professional services, including virtual physician visits and surgery. Charges for an assistant surgeon are covered up to 20% of the usual, reasonable and customary charge of the primary surgeon, but standby availability will not be deemed to be a professional service and therefore is not covered hereunder.
- Dressings, sutures, casts or other supplies which are medically necessary and administered by or under the supervision of a physician, but excluding nebulizers, oxygen tanks, diabetic supplies, other supplies for use or application at home, and all devices or supplies for repeat use at home, except durable medical equipment.
- Diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, intelligence, behavioral and educational testing are not included).
- Artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the replacement or repair thereof.
- Reconstructive surgery when the reconstructive surgery is directly related to a surgery which is covered hereunder.
- Hemodialysis and the charges by the hospital for processing and administration of blood or blood components but not the cost of the actual blood or blood components.
- Oxygen and other gasses and their administration by or under the supervision of a physician.
- Anesthetics and their administration by a physician.
- Care in a licensed extended care facility upon direct transfer from an acute care hospital.
- Home nursing care in bed by a qualified licensed professional, provided by a home health care agency upon direct transfer from an acute care hospital and only in lieu of medically necessary inpatient hospitalization.
- Emergency local ambulance transport necessarily incurred in connection with injury or illness resulting in inpatient hospitalization.
- Emergency dental treatment and dental surgery necessary to restore or replace natural teeth lost or damaged in an accident which was covered under this insurance.
- Medically necessary rental of durable medical equipment (consisting of a standard basic hospital bed and or a standard basic wheelchair) up to the purchase prices.
- Physical therapy while inpatient if prescribed by a physician who is not affiliated with the physical therapy practice, necessarily incurred to continue recovery from a covered injury or illness.
- Injury or illness resulting from participation in sports or athletic activities not otherwise excluded under this insurance.
YOU ARE NOT COVERED IF:
1. Expenses arise directly or indirectly from anything in the General Exclusions.
Emergency Medical Evacuation
YOU ARE COVERED FOR:
- Emergency air transportation to a suitable airport nearest to the hospital where you will receive treatment; and
- Emergency ground transportation necessarily preceding emergency air transportation; and from the destination airport to the hospital where you will receive treatment; and
- The cost of an economy one-way air and/or ground transportation ticket for you from the area where you were hospitalized following a covered Emergency Medical Evacuation to the area where you were initially evacuated from or to the terminal serving the area of your principal residence.
YOU ARE NOT COVERED unless you fulfill the following conditions:
- The evacuation is recommended by the attending physician who certifies that it is medically necessary and that transportation by any other method would result in the loss of your life or limb;and
- The evacuation is agreed upon by you or your relative; and
- Following a covered Emergency Medical Evacuation when the attending physician states that it is medically necessary for you to return to your home country or to the area from which you wereinitially evacuated for continued treatment, recuperation and recovery; and
- Travel arrangements, excluding Emergency Local Ambulance, are approved in advance and coordinated by us.
YOU ARE NOT COVERED IF:
- The illness or injury giving rise to the expense is not covered under this insurance; or
- Medically necessary treatment, services and supplies can be provided locally; or
- For emergency air or ground transportation, if transportation by any other method would not result in the loss of your life or limb; or
- The condition giving rise to the Emergency Medical Evacuation did not occur suddenly and unexpectedly and without advance warning, either in the form of physician recommendation orsymptoms which would have caused a prudent person to seek medical attention prior to the onset of the emergency; or
- Expenses arise directly or indirectly from anything in the General Exclusions.
We will provide Emergency Medical Evacuation only to the nearest hospital that is qualified to provide the medically necessary treatment, services and supplies to prevent your loss of life or limb.
The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.
Notwithstanding the foregoing, and if you are visiting the U.S., we will pay for expenses to return you to your home country if the attending physician and our medical consultant agree that transfer to your home country is more appropriate than transfer to the nearest qualified hospital.
Repatriation of Remains
YOU ARE COVERED FOR:
1. Air or ground transportation of bodily remains or ashes to the airport or ground transportation terminal nearest your principal residence; and
2. Reasonable costs of preparation of the remains necessary for transportation.
YOU ARE NOT COVERED unless you fulfill the following conditions:
- The illness or injury giving rise to the expense are covered under this insurance; and
- Travel arrangements are approved in advance and coordinated by us.
YOU ARE NOT COVERED IF:
1. Expenses arise directly or indirectly from anything in the General Exclusions.
We are held harmless and shall not be held liable for loss of or any damage or other impairment to bodily remains incurred during the repatriation process or otherwise.
The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.
Local Burial or Cremation
YOU ARE COVERED FOR:
- For you to be buried or cremated in the country of death in lieu of Repatriation of Remains up to the specified benefit maximum.
YOU ARE NOT COVERED unless you fulfill the following conditions:
- The illness or injury giving rise to the expense is covered under this insurance; and
- Travel arrangements are approved in advance and coordinated by us.
YOU ARE NOT COVERED IF:
- The death occurs in your home country; or
- The Emergency Medical Evacuation or Repatriation of Remains benefit is used; or
- Expenses arise directly or indirectly from anything in the General Exclusions.
The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.
Sports and Activities
YOU ARE COVERED FOR:
- You are covered for taking part in amateur/non-professional sports and activities, unless it is excluded below. Coverage is for recreational purposes incidental to a trip.
YOU ARE NOT COVERED unless you fulfill the following conditions:
- You must ensure that appropriate safety equipment (such as protective headwear, life jackets etc.) are worn at all times.
YOU ARE NOT COVERED IF:
- The activity is organized athletics involving regular or scheduled practice and/or games; or
- The activity is performed in a professional capacity or for any wage, reward, or profit; or
- Expenses arise directly or indirectly from anything in the General Exclusions; or
- Any of the excluded items listed below:
- All-Terrain Vehicles
- American Football
- Aussie Rules Football
- Aviation (except when traveling solely as a passenger in a commercial aircraft)
- Base Jumping
- Big Game Hunting
- Bobsleigh
- Boxing
- Cave Diving
- Cliff Jumping
- Hang-Gliding
- Heli-Skiing
- Hot Air Ballooning as a Pilot
- Ice Hockey
- Jousting
- Kite-Surfing
- Luge
- Martial Arts
- Modern Pentathlon
- Motorized Dirt Bikes
- Mountaineering at elevations of 4,500 meters or higher
- Outdoor Endurance Events
- Parachuting
- Paragliding
- Parasailing
- Powerlifting
- Quad Biking
- Racing by any Animal, Motorized Vehicle, or BMX, and Speed Trials and Speedway
- Rugby
- Running with the Bulls
- Skeleton
- Sky Surfing
- Snow Skiing and Snowboarding, except recreational downhill skiing, snowboarding and/or cross-country snow skiing (no cover provided for recreational downhill skiing or snowboarding while skiing away from prepared and marked in-bound territories and/or for any skiing or snowboarding against the advice of the local ski school or local authoritative body)
- Snow Mobiles
- Spelunking
- Sub Aqua Pursuits involving underwater breathing apparatus unless accompanied by a certified instructor at depths less than 10 meters, or PADI/NAUI/SSI certified
- Tractors
- Whitewater Rafting
- Wrestling
Terrorism
YOU ARE COVERED FOR:
- Eligible Medical Expenses for treatment of injuries and illnesses resulting from an Act of Terrorism, up to the limit set forth in the Schedule of Benefits and Limits, provided all of the following conditions are met.
YOU ARE NOT COVERED unless you fulfill the following conditions:
- The injury or illness does not result from the use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon;
- You have no direct or indirect involvement in the Act of Terrorism;
- The Act of Terrorism is not in a country or location where the U.S. Department of State has issued a level 3 or higher travel advisory that has been in effect within the 60 days immediately prior to your date of arrival; and
- You have not failed to depart a country or location within 10 days following the date a level 3 or level 4 travel advisory for that country or location is issued by the United States government.
YOU ARE NOT COVERED IF:
- Loss, damage, cost or expense directly or indirectly caused by, resulting from or in connection with any of the following regardless of any other cause or event contributing concurrently or in any other sequence to the loss, damage, cost or expense:
- War, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power;
- The use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon; however, this exclusion shall not apply where you are exposed to nuclear radioactive and/or radioactive material for the purpose of medical treatment;
- Any Act of Terrorism, not specifically covered above;
- Coverage for loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to (a), (b) or (c) above;
- Expenses arise directly or indirectly from anything in the General Exclusions.
For the purpose of this insurance, an “Act of Terrorism” means an act, including but not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.
If we allege that by reason of this exclusion, any loss, damage, cost or expense is not covered by this insurance, the burden of proving the contrary shall be upon you.
In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.
The following definitions apply to Terrorism:
Cyber means the use or operations, as a means for inflicting harm, of any computer, computer software program, malicious code, computer virus or process or any other electronic system.
Acute Pre-Ex Coverage
Pre-Existing Medical Conditions
This policy does not cover charges, in whole or in part, resulting from, related to, arising from, or necessitated by a pre-existing condition(s).
Pre-existing Condition means 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 2 years prior to the effective date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, treated, or disclosed to us prior to the effective date, and including any and all subsequent, chronic or recurring complications or consequences related thereto or resulting or arising therefrom.
For the purposes of the Complications of Pregnancy coverage offered hereunder, pregnancy will not be included within the definition of a pre-existing condition.
Exclusion
Excluded Conditions, Treatments (includes Diagnoses, Tests, and Examinations), Services, Supplies, Acts, Omissions, and/or Events:
1. Illness that begins by occurrence of symptoms and/or receipt of treatment within the first two (2) days of coverage beginning with and including the certificate effective date, if coverage was purchased on the same day as the coverage effective date.
2. Pre-existing conditions.
3. Outpatient physical therapy.
4. Outpatient prescription drugs.
5. Mental health disorders.
6. Birth defects and congenital conditions. Birth defects are deemed to include hereditary conditions.
7. Pregnancy except for diagnostic testing related to a covered injury or illness, complications of pregnancy, termination of pregnancy, routine prenatal care, childbirth, postnatal care, and charges incurred by a child under the age of fourteen (14) days.
8. Impotency or sexual dysfunction.
9. All sexually transmitted diseases and conditions except for diagnostic testing related to a covered injury or illness.
10. HIV, AIDS, or ARC, and all diseases caused by and/or related to HIV.
11. All forms of cancer / malignant neoplasm.
12. Substance abuse or addiction or conditions that may be attributed to substance abuse or addictions and direct consequences thereof.
13. Acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, hypertrophic and atrophic conditions of skin, nevus.
14. Sleep apnea or other sleep disorders.
15. Obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass surgery.
16. Intentional self-inflicted injury or illness and/or suicide or attempted suicide whether sane or insane.
17. Injury or illness sustained that is due wholly or partially to the effects of alcohol, illegal , or drugs not taken in accordance with treatment prescribed by a physician and except drugs prescribed for the treatment of substance abuse, or injury sustained while under the influence of drugs or alcohol as (i) defined under the law of the jurisdiction, or (ii) with a .08 Blood Alcohol Content (BAC), whichever is lower; or (iii) an expert’s report, such as that of a medical practitioner or forensic expert; (iv) the witness report of a third party, or (v) your own admission; or (vi) the description of events you described to us or you had described to any treating medical professional (such as a paramedic, nurse, doctor) or attending emergency service member as documented in their records.
18. Routine medical examinations, including but not limited to vaccinations, immunizations, annual check- ups, the issue of medical certificates and attestations, and examinations as to the suitability of employment or travel.
19. Treatment of the temporomandibular joint.
20. Promotion or prevention of conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
21. Organ or tissue transplants or related services.
22. Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
23. Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations, except as provided for under Emergency Eye Exam.
24. Orthoptics and visual eye training.
25. Orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or toenails.
26. Hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed, unless prescribed due to loss resulting from a covered injury or illness.
27. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinesiotherapy.
28. Psychometric, intelligence, competency, behavioral and educational testing.
29. Cosmetic or aesthetic reasons, except for reconstructive surgery when such surgery is directly related to and follows a surgery which was covered hereunder.
30. Modifications of the physical body intended to improve the psychological, mental or emotional well- being, including but not limited to sex-change surgery.
31. Exercise programs, whether or not prescribed or recommended by a physician.
32. Incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
33. Cryo preservation and implantation or re-implantation of living cells.
34. Genetic or predictive testing.
35. Investigational, experimental or for research purposes.
36. While confined primarily to receive custodial care, educational or rehabilitative care, or any medical treatment in any establishment for the care of the aged, except rehabilitative care received upon direct transfer from an acute care hospital.
37. Not medically necessary.
38. Not administered by or under the supervision of a physician, and products that can be purchased without a doctor's prescription.
39. Provided by a relative, family member or any person who ordinarily resides with you.
40. Provided by a chiropractor.
41. Provided at no cost to you.
42. Failure to keep a scheduled appointment.
43. Payable under any government system, including the Australian Medicare system.
44. Payable under Worker’s Compensation or Employer’s Liability Laws, or by any coverage provided or
required by law.
45. Charges exceeding usual, reasonable and customary.
46. Charges resulting from or occurring during the commission of a violation of law, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
47. Any illness or injury incurred as a result of epidemics, pandemics, public health emergencies, natural disasters, or other disease outbreak conditions that may affect a person’s health when, prior to your effective date, any of the following were issued:
a. The United States Centers for Disease Control & Prevention had issued a Warning/Alert Level 3 or higher for a location or destination, including common carriers; or
b. The United States Centers for Disease Control & Prevention had issued a Global or Worldwide Warning/Alert Level 3 or higher.
This exclusion is applicable when 1) any of the above were in effect within sixty (60) days immediately prior to your effective date or 2) within ten (10) days following the date the alert/warning is issued you have failed to depart the country or location. This exclusion does not apply to charges resulting from COVID-19/SARS-CoV-2.
48. War, military action or while on duty as a member of a police or military force unit.
49. Travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, and Repatriation of Remains sections of this insurance.
50. Incurred outside your certificate period.
51. Submitted to us for payment more than sixty (60) days after the last day of the certificate period.
52. When departure from the home country is to obtain treatment in the destination country/countries.
53. Complications or consequences of a treatment or condition not covered hereunder.
54. Not included as Eligible Expenses as described herein.
PPO Network
U.S. Preferred Provider Organization (PPO) Requirements
Nothing contained in this insurance restricts or interferes with your right to select the hospital, physician or other medical service provider of your choice. Nothing contained in this insurance restricts or interferes with the relationship between you and the hospital, physician or other providers with respect to treatment or care of any condition, nor your right to receive, at your own expense, services and/or supplies that are not covered under this insurance.
To comply with the United States Preferred Provider Organization (PPO) requirements, you must receive medical treatment from PPO providers while in the United States. If you receive treatment from a PPO provider, we will remit payment for eligible expenses directly to the provider.
You may review a listing of hospitals, physicians and other medical service providers included in the PPO Network for the area where you will be receiving treatment by visiting WorldTrips’ website located at:www.worldtrips.com. For assistance locating a provider, contact us at 1-800-605-2282.
Cancel
We hope you are happy with the cover this policy provides. However, if after reading it, this insurance does not meet with your requirements, please notify us of your wish to cancel and we will refund your premium.
Premiums will be refunded in full if a cancellation request is received prior to the certificate effective date. Premiums may be refunded after the certificate effective date subject to the following provisions:
- A $25 cancellation fee will apply for administrative costs incurred by us; and
- Only the prorated portion of the premium will be refunded; and
- You cannot have filed any claims to be eligible for premium refund.
Claim
Claims
This insurance policy has in it a Claims Procedure which tells you what steps you must take to file a claim and explains our obligations to you. Beginning on the last day of your certificate period, you shall have sixty (60) days to provide us proof of claim.
Appeals and Complaints
This insurance policy has in it an Appeals and Complaints Procedure which tells you what steps you can take if you wish to make an appeal or complaint. The written appeal must be submitted within ninety (90) days from the later of the date the claim was denied or the termination date of the policy.
Claims Notification
All claims and related claim information, including a proof of claim, should be submitted to WorldTrips at the contact information below, or online as soon as possible.
Online: https://www.worldtrips.com/customer-service
Postal Mail: WorldTrips
P.O. Box 240358
Apple Valley, MN 55124 USA
Proof of Claim
You must send proof of claim for any expenses that you are requesting to be paid by us. This includes treatment or services for which the medical provider bills us directly. No payments will be made by us without you first submitting a proof of claim.
We must receive proof of claim for an incident within sixty (60) days of the last day of your certificate period
(or for claims incurred during a benefit period, sixty (60) days from the date the claim is incurred). A proof of claim must include all of the following:
1. A completed and signed Claimant’s Statement and Authorization form, together with any/all
required attachments;
2. Itemized bills from physicians, hospitals and other medical providers; and
3. Receipts for any expenses which have already been paid by you or on your behalf.
Subsequent to receipt of proof of claim, we may, at our sole discretion, request and require additional information, including but not limited to medical records necessary to confirm whether coverage exists for any claim prior to payment thereof.
Claims Cooperation
You shall provide assistance and cooperate with us or our representatives in obtaining any other records we or they feel necessary to evaluate your claim or any incident giving rise to your claim. You shall provide, when asked, all authorizations necessary to obtain your medical records. If you do not fully cooperate with us and/or our investigation of the claim, we shall not be liable to pay any claim.
Access to Additional Materials
You shall provide us, or our designated representatives, all information, documentation and medical information that we or they may reasonably require during the term of this policy, or until all claims have been resolved, whichever is later.
Other Insurance
We shall not pay any claim if there is other insurance which would, or would but for the existence of this insurance, pay such claim. This insurance will apply with respect to expenses in excess of the amount paid or payable under such other insurance. We shall not pay any claim in respect to care, treatment, services or supplies furnished by any insurance, program or agency funded by any government.
Appeal and Complaints Procedure
Appealing a Claim
In the event we deny all or part of a claim under this insurance, you may file a written appeal with us. The written appeal must be submitted within ninety (90) days from the later of the date the claim was denied or the termination date of the policy. The appeal must include sufficient information to identify the claim under appeal and must specify the reason(s) for the appeal with supporting documentation, if applicable.
Please submit your written appeal online, by email, or by postal mail at the following:
Online: https://www.worldtrips.com/customer-service
Email: appeals@worldtrips.com
Postal Mail: WorldTrips Appeals
P.O. Box 241778
Apple Valley, MN 55124
USA
When we receive the appeal, we will review the claim and a written response will be sent to you. After you receive our response to the appeal, you may initiate a second appeal. With our receipt of the second appeal, medical and/or claims personnel who were not involved in the original claim determination or the initial appeal will review the claim. A final determination will be made and a letter will be sent to you.
Please note that appealing a claim is not a requirement to following the complaints procedure detailed below.
Misrepresentation or Fraud
Application
We rely on the statements made by you on the application in connection with the making of the application in determining whether or not the individual(s) included on the application meets the eligibility requirements for insurance hereunder. Any determination by us of a misstatement or misrepresentation (whether intentional or not), concealment or fraud in the member’s application, or in relation to any statement or warranty made by the member or their authorized representative, whether in writing or otherwise, to us or our representatives, on or in connection with the application shall immediately render this insurance null and void and all claims hereunder shall be deemed non-payable in addition to any and all other remedies available to us.
Claims
We rely on the statements made by the member on the claimant’s statement and in connection with the submission of any claim hereunder in determining whether or not and to what extent benefits under this insurance may be payable. Any misstatement or misrepresentation (whether intentional or not), concealment or fraud in the making of any claim hereunder shall immediately render this insurance null and void and all
claims hereunder shall be deemed non-payable and we reserve our rights regarding any and all other remedies available to us. If any claim under this insurance shall be in any respect fraudulent or if any fraudulent means or devices are used by the member or anyone acting on their behalf, this insurance shall be null and void and all claims hereunder shall be deemed non-payable and we reserve our rights regarding any and all other remedies available to us.
Renew
Renewal
The coverage provided under this Master Policy is for a maximum duration of twelve (12) months. Any extension of coverage is based upon the eligibility rules in force and is solely at our discretion.