Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: Lloyd's of London

  • PPO Network (Within PP0 Network): 80% after the deductible, up to the overall maximum limit.
  • PPO Network (Outside PP0 Network): Usual, reasonable, and customary (URC).
  • Eligibility: Non US Citizen Age 14-64 travelling to USA.
  • Coverage length: Min 5 days to 364 days.
  • Provider Network: Member will be receiving treatment by accessing the Internet website for HCC - Medical Insurance Services, LLC at: www.hccmis.com.
  • Renew Online: Any extension or renewal is based upon the eligibility rules in force at the time of renewal and is solely at the  discretion of Underwriter.
  • ID card & Visa Letter comes in email instantly.

Benefit

 

Basic

Overall Maximum Limit

$200,000

Maximum Injury or Illness

$100,000

Pre-Existing Condition Waiting Period

N/A

Deductible (except emergency room)

$100 in network/$150 out of network

ER Deductible

$500/incident

Coinsurance – Claims Incurred in the U.S.

 
  •  In-Network Payment

80% after the deductible, up to the overall maximum limit.

  • Out-of-Network Payment

Usual, reasonable, and customary (URC)

Coinsurance - Claims Incurred Outside the U.S.

100% after the deductible, up to the overall maximum limit.

Local Ambulance

$300 per injury/illness

Prescription Drugs

For outpatient prescriptions 50% of actual charges

Wellness

N/A

Physical Therapy & Chiropractic Care

$25 per visit per day.

Dental Treatment due to Accident

N/A

Mental Health Disorders

Outpatient: $50 max. per day, $500 max. Inpatient: Usual, reasonable and customary charges up to $5,000

Maternity Care for Covered Pregnancy

N/A

Intercollegiate, Interscholastic, Intramural or Club Sports

N/A

Dental Treatment to Alleviate Pain

N/A

Personal Liability

N/A

Repatriation of Remains

$25,000 lifetime max.

Terrorism

$50,000 lifetime max.

Accidental Death & Dismemberment

$10,000 lifetime max.

Emergency Reunion (Max. 15 days)

$1,500

Charges for the following conditions, treatments (including diagnoses, tests, and examinations), services, supplies, acts, omissions, and/or events are excluded from coverage hereunder:

  1. Congenital illnesses.
  2. Immunizations and other diagnostic labs, x-rays, and procedures for screening or preventative purposes.
  3. Dental treatment and treatment of the temporomandibular joint.
  4. Mental health disorders if treatment is obtained at a student health center.
  5. Physical therapy if treatment is obtained at a student health center.
  6. Chiropractic treatment, unless ordered in advance by a physician for medically necessary treatment related to a covered injury or illness, and not obtained at a student health center.
  7. Routine pre-natal care, pregnancy, child birth, post-natal care, and nursery care of a newborn, unless directly related to a covered pregnancy.
  8. Elective termination of pregnancy.
  9. Promotion or prevention of conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
  10. Venereal disease, including all sexually transmitted diseases and conditions.
  11. HIV, AIDS, or ARC, and all diseases caused by and/or related to HIV.
  12. Organ or tissue transplants or related services.
  13. Self-inflicted injury or illness and/or suicide or attempted suicide whether sane or insane.
  14. Injury sustained that is due wholly or partially to the effects of intoxication or drugs other than drugs taken in accordance with treatment prescribed by a physician and except drugs prescribed for the treatment of substance abuse.
  15. Voluntarily using any drug, narcotic or controlled substance, unless as prescribed by a physician.
  16. 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.
  17. Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
  18. 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.
  19. Orthoptics and visual eye training.
  20. 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.
  21. Hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed.
  22. Acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, hypertrophic and atrophic conditions of skin, nevus.
  23. Sleep apnea or other sleep disorders.
  24. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.
  25. Psychometric, intelligence, competency, behavioral and educational testing.
  26. 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.
  27. Cosmetic or aesthetic reasons, except for reconstructive surgery when such surgery is directly related to and follows a surgery which was covered hereunder.
  28. Modifications of the physical body intended to improve the psychological, mental or emotional well-being, including but not limited to sex-change surgery.
  29. Obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass surgery.
  30. Exercise programs, whether or not prescribed or recommended by a physician.
  31. Incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
  32. Charges resulting from a disease outbreak in a country or location for which the U.S. Centers for Disease Control and Prevention (CDC) has issued a Level 3 Travel Warning if a) the warning has been in effect within the 6 months immediately prior to your date of arrival, or b) within 10 days following the date the warning is issued you have failed to depart the country or location.
  33. Investigational, experimental or for research purposes.
  34. Complications or consequences of a treatment or condition not covered hereunder.
  35. Incurred outside your certificate period.
  36. Submitted to us for payment more than 60 days after the last day of the certificate period.
  37. Exceeding usual, reasonable and customary.
  38. Not medically necessary.
  39. Not administered by or ordered by a physician.
  40. Provided by a relative, family member or any person who ordinarily resides with you.
  41. Provided at no cost to you.
  42. Telephone consultations or failure to keep a scheduled appointment.
  43. When departure from the home country is to obtain treatment in the destination country/countries.
  44. Travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Repatriation of Remains, and Emergency Reunion sections of this insurance.
  45. Payable under any government system, including the Australian Medicare system.
  46. War, military action or while on duty as a member of a police or military force unit.
  47. Not included as Eligible Expenses as described herein.

Charges resulting directly or indirectly from any pre-existing conditions are excluded from this insurance.

Pre-existing Condition means any

  1. condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the 12 months immediately preceding the certificate effective date;
  2. condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 12 months immediately preceding the certificate effective date;
  3. injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 12 months immediately preceding the certificate effective date.

To comply with the United States Preferred Provider Organization requirements, the Member must receive medical treatment from PPO providers while in the United States. If the Member chooses to comply with the PPO requirements, and the expenses are incurred in a PPO provider, Underwriters will waive the Coinsurance applicable to the expenses.Members may review a listing of Hospitals, Physicians and other medical service providers included in the PPO Network for the area where the Member will be receiving treatment by accessing the Internet website for HCC Medical Insurance Services.

Any extension or renewal is based upon the eligibility rules in force at the time of renewal and is solely at the discretion of Underwriter.

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 cancellation request is received prior to the certificate effective date.

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

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

Claim Procedures

You must submit a claim for any expenses to be paid by us. This includes treatment or services for which you expect the medical provider is to bill us directly. No payments will be made by us without you first submitting a claim.

Notice of claim, Claimant’s Statement and Authorization, and proof of claim must be mailed to:

Tokio Marine HCC MIS Group
P.O. Box 2005
Farmington Hills, MI 48333-2005

Proof of Claim

When we receive notice of claim, we will provide you with forms for filing proof of claim. The following is considered to be proof of claim:

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

You shall have 60 days beginning on the last day of the certificate period to submit proof of claim to us (unless medical services were rendered after the certificate termination date, in which case you shall 60 days from the date the claim is incurred). 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 the validity of any claim prior to payment thereof.

Claims Cooperation

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

Access to Additional Materials

You shall provide us, or our designated representatives, all information, documentation, 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 program or agency funded by any government.

Arbitration

If any dispute shall arise as to the amount to be paid under this insurance such dispute shall be referred to arbitration in accordance with procedures of the American Arbitration Association. Where any dispute is by this provision referred to arbitration, the making of an award shall be a condition precedent to any right of action against us.

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