MEMBER ELIGIBILITY

Persons who are non-US citizens, fourteen (14) days and older who are traveling to the United States for business, pleasure, or to study, have arrived in the United States within the three hundred and sixty-fix (365) days preceding the proposed Effective Date of the program, who have paid premium as outlined in the enrollment application, and who have completed the enrollment form in complete detail are eligible for Inbound USA. The Company maintains its right to investigate to verify that the eligibility requirements have been met. If and whenever the Company discovers that the eligibility requirements have not been met, its only obligation is refund of premium.

For the purposes of this program, persons fourteen (14) days of age through sixty- nine (69) years are considered one class of Insured Person, and persons age seventy (70) and over are considered another class of Insured Person.

The eligibility date for Dependent Child(ren) of a Named Insured (as defined) shall be determined in accordance with the following: (1) If a Named Insured has Dependent Child(ren) on the date he or she is eligible for insurance; or (2) If a Named Insured acquires Dependent Child(ren) after the Effective date, such Dependent Child(ren) becomes eligible on the date the Insured acquires a Dependent Child who is within the limits of a dependent, unmarried child set forth in the “Definition” section of the policy. Dependent Child(ren) eligibility expires concurrently with that of the Named Insured.

EFFECTIVE DATE

Effective Date under the program shall become effective at 12:01 AM North American Eastern Time on the latest of the following dates:

1. The Insured Person’s departure from his Home Country; or

2. The date the application and premium are received by the Administrator; or

3. The date the application and premium are accepted by the Administrator; or

4. The date requested on the application.

Dependent Child(ren) coverage will not be effective prior to that of the Named Insured. EXPIRATION DATE

The coverage provided with respect to the Named Insured shall terminate at 12:01 AM North American Eastern Time on the earliest of the following dates:

1. The date shown on the insurance confirmation card, for which the premium is paid; or

2. The date the Insured Person returns to his Home Country; or

3. Three hundred and sixty four (364) days after the Insured Person’s original effective date; or

4. The date the Insured Person becomes a United States citizen; or

5. The date of entry into active duty military service.

6. The date the master policy terminates (unless the Company agrees, in writing, to permit coverage to continue to the end of the period for which Premiums have been paid in lieu of a return of unearned premiums); or

7. The date the master policy terminates (unless the Company agrees, in writing, to permit coverage to continue to the end of the period for which premiums have been paid in lieu of a return of unearned premiums);

8.In addition, for Dependent Child(ren), coverage expires the date the Named Insureds(s) coverage expires or the date they cease to be considered a Dependent Child.

DEFINITIONS

“Accident” or “Accidental” shall mean an event, independent of Illness or self-inflicted means, which is the direct cause of bodily Injury to an Insured Person.

“Acute Onset of a Pre-existing Condition(s)” shall mean a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms and is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the effective date of the policy. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to the Effective Date of coverage.

“Benefit Period” shall mean the duration of time following a covered Injury or Sickness in which to receive Medically Necessary Covered Expenses. Treatment must be performed within one hundred and eighty-two (182) days following the Injury or Sickness.

“Certificate” shall mean the summary of the terms of Coverage, which includes this document, the Insured Person’s Application and any endorsements or amendments that will attach during the Insured Person’s Period of Coverage.

“Company” shall mean Certain Underwriters at Lloyd’s, London “Coverage Period” or “Period of Coverage” shall mean the period between the Individual Effective Date of Coverage and the Individual Termination Date of Coverage for this Certificate, which is stated on the Insured Person’s ID Card.

"Covered Event" shall mean the Covered Expenses for an Illness or an Accidental bodily Injury necessitating medical Treatment by a Service Provider as defined in this Certificate.

“Covered Expenses” or “Covered Medical Expenses” shall mean expenses which are for Medically Necessary services, supplies, care, or Treatment; due to Illness or Injury, as described in the Certificate; prescribed, performed or ordered by a licensed Physician and/or Service Provider; incurred by the Insured Person during their Period of Coverage; and which are (1.) listed in the Schedule of Benefits, (2.) not excluded in the Exclusions and (3.) do not exceed the maximum limits stated in the Schedule of Benefits.

“Deductible” means the amount stated in the Schedule of Benefits or any endorsement to the policy as a deductible. Such amount will be subtracted from the amount or amounts charged and otherwise payable as Covered Medical Expenses. The deductible will apply per occurrence (for each Injury or Sickness) as specified in the Schedule of Benefits.

“Dependent Child(ren)” means a Named Insured’s dependent, unmarried children living with the Named Insured. This includes stepchildren, legally adopted children and children of adopting parents pending adoption procedures. Children shall cease to be dependent on the first to occur of: (1) the end of the month in which they marry; or (2) the end of the month in which they attain the age of nineteen (19) years. The attainment of the limiting age will not operate to terminate the coverage of such child while the child is and continues to be both: (1) incapable of self- sustaining employment by reason of mental retardation or physical handicap; and (2) chiefly dependent upon the Insured Person for support and maintenance. Proof of such incapacity and dependency shall be furnished to the Company: 1) by the Named Insured; and 2) within thirty-one (31) days of the child’s attainment of the limiting age. Subsequently, such proof must be given to the Company upon request following the child’s attainment of the limiting age. If a claim is denied under the policy because the child has attained the limiting age for dependent children, the burden is on the Insured Person to establish that the child is and continues to be handicapped as defined by subsection (1) and (2).

"Disablement" as used with respect to medical expenses shall mean an Illness or an Accidental bodily Injury necessitating medical treatment by a Physician as defined in this Policy.

"Eligible Benefits" shall mean expenses which are for Medically Necessary services, supplies, care, or Treatment; due to Illness or Injury; prescribed, performed or ordered by a licensed Physician and/or Service Provider; incurred by the Insured Person during their Period of Coverage; and which are (1.) listed in the Schedule of Benefits, (2.) not excluded in the Exclusions and (3.) do not exceed the maximum limits stated in the Schedule of Benefits

“Emergency” shall mean 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 24 hours.

"Home Country" shall mean the country where an Insured Person has his or her true, fixed and permanent residence.

"Hospital" shall mean a place that 1.) is legally operated for the purpose of providing medical care and Treatment to Sick or Injured persons for which a charge is made that the Insured Person is legally obligated to pay in the absence of insurance 2.) provides such care and Treatment in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use; 3.) provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4.) operates under the supervision of a staff of one or more Physicians. Hospital also means a place that is accredited as a Hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Heath Care Organizations (JCAHO). Hospital does not mean: -a Convalescent, nursing, or rest home or facility, or a home for the aged; -a place mainly providing Custodial, Educational, or Rehabilitative Care; or -a facility mainly used for the Treatment of drug addicts or alcoholics.

“Hospital Confined” or “Hospital Confinement” means confined in a Hospital for at least 18 hours by reason of an Injury or Sickness for which benefits are payable.

"Injury" shall mean bodily Injury listed in the most recent edition of the International Classification of Diseases and caused solely and directly by Accidental, external, and visible means occurring while this Certificate is in force and resulting directly and independently of all other causes resulting in a Covered Event under this Program.

"Inpatient" shall mean a person who is confined in an institution for a period of 24 hours or more and is charged for room and board.

"Insured Person(s)" shall mean a person eligible for Coverage under the Certificate as stated on the ID Card, who has applied for Coverage and is named on the Application and for whom the Company has Approved for Coverage and accepted the corresponding Premium. This may be the Primary Insured Person or Dependent(s).

“Intensive Care or Coronary Unit” shall mean a cardiac care unit or other unit or area of a Hospital which meets the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.

“Medical Emergency” means the occurrence of a sudden, serious and unexpected Sickness or Injury. In the absence of immediate medical attention, a reasonable person could believe this condition would result in: (1) Death; (2) Permanent placement of the Insured’s health in jeopardy; (3) Serious impairment of bodily functions; or (4) Serious and permanent dysfunction of any body organ or part. Expenses incurred for “Medical Emergency” will be paid only for Sickness or Injury which fulfills the above conditions. These expenses will not be paid for minor injuries or minor Sicknesses.

"Medically Necessary or Medical Necessity" shall mean services, Treatment or supplies received by the Insured Person that are determined by the Company to be: 1.) appropriate and necessary for the symptoms, diagnosis, or direct care and Treatment of the Insured Person's medical conditions; 2.) within the standards the organized medical community deems good medical practice for the Insured Person's condition; 3.) not provided solely for educational purposes or primarily for the convenience of the Insured Person, the Insured Person's Physician or another Service Provider or person; 4.) not Experimental / Investigational and/or for Research; and 5.) not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate Treatment. For Hospital stays, this means that acute care as an Inpatient is necessary due to the kinds of services the Insured Person is receiving or the severity of the Insured Person's condition, in that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting. The fact that any particular Physician may prescribe, order, recommend, or approve a service, Treatment, supply or level of care, does not of itself, make such Treatment Medically Necessary or make the charge a Covered Expense under this Certificate.

"Mental Illness" or “Mental and Nervous Disorder” shall mean Mental, emotional, and psychiatric disorders, Illnesses or conditions (whether organic or non-organic, whether biological, non- biological, genetic, chemical or non-chemical in origin). Mental and nervous disorders include, but are not limited to psychoses; neurotic disorders; bipolar disorders; affective disorders; personality disorders; psychological or behavioral abnormalities, associated with transient or permanent dysfunction of the brain or related neurohomonal systems; and disorders, conditions, and Illnesses listed in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders IV-R or the most recent edition of the International Classification of Diseases ICD-9-CM, which is the required reporting tool for all diagnoses and diseases to all U.S. Public Health Service and Health Care Financing Administration programs on the date the medical care or Treatment is rendered to an Insured Person.

"Outpatient" shall mean a person who receives care in a Hospital or another institution, including; ambulatory surgical center; convalescent/skilled nursing facility; or Physician's office, for an Illness or Injury, but who is not confined and is not charged for room and board.

"Physician” or “Surgeon" shall mean a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform Surgery in accordance with the laws of the jurisdiction where such professional services are performed.

“Physiotherapy” shall mean physical therapy, recommended by a Physician for the treatment of a specific Covered Event and administered by a licensed physical therapist.

“Policyholder” means Global International Trust, Washington DC.

"Pre-Existing Condition" shall mean any medical condition, Sickness, Injury, illness, disease, Mental Illness or Mental Nervous Disorder, regardless of the cause including any congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting therefrom that with reasonable medical certainty existed at the time of application or within the one hundred and eighty (180) days (three hundred and sixty five (365) days for Insured Persons 70 and older) immediately prior to the Insured Person’s Effective Date under the policy, whether or not previously manifested, symptomatic, known, diagnosed, treated or disclosed. This specifically includes but is not limited to any medical condition, Sickness, Injury, illness, disease, Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought treatment duringthe one hundred and eighty (180) days (three hundred and sixty five (365) days for Insured Persons 70 and older) immediately preceding the effective date of coverage under this policy.

“Prescription Drugs” means: 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a prescription legend drug; 3) any other drugs which under the applicable state or federal law may be dispensed only upon written prescription of a Physician; and 4) injectable insulin. "Service Provider" shall mean a Hospital, Hospice, Convalescent/skilled nursing facility, ambulatory surgical center, psychiatric Hospital, community mental health center, residential treatment facility, psychiatric treatment facility, alcohol or drug dependency treatment center, birthing center, Physician, Dentist, chiropractor, licensed medical practitioner, nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the Company approves to provide services under the Certificate.

“Sickness” shall mean Illness or Disease of any kind listed in the most recent edition of the International Classification of Diseases. All related conditions and recurrent symptoms of the same or a similar condition will be considered one Sickness.

“Sound, Natural Teeth” means natural teeth, the major portion of the individual tooth is present, regardless of fillings or caps; and is not carious, abscessed or defective.

“Treatment” shall mean medical or surgical management of a patient designed to resolve the Illness or Injury based on standard and accepted medical practice. For purposes of this Certificate, the course of action will only include those scheduled and approved benefits, for which the Insured Person is eligible.

GENERAL PROVISIONS

Entire Contract; Changes: The Certificate, including the Application, Schedule of Benefits, endorsements and the attached papers, if any, constitutes the entire contract of Insurance. No change in the Certificate shall be valid until approved by an executive officer of the Company and unless such approval is endorsed hereon. No agent has authority to change this Certificate or to waive any of its provisions;

Physical Examination and Autopsy: The Company at its own expenses shall have the right and opportunity to examine the person of any individual whose Injury or Illness is the basis of claim when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death, where it is not forbidden by law.

Grace Period: There is no Grace Period associated with this program. Not in Lieu of Worker's Compensation: This Insurance is not in lieu of and does not affect any requirements for coverage by Worker's Compensation Insurance. Certificate of Insurance: The Company shall issue to each Insured Person an individual Program Summary (Certificate of Insurance), which shall state the essential features of Insurance to which such person is entitled and to whom benefits are payable, if required to do so by the laws of the locality in which the Insured Person resides when his Insurance becomes effective. Data Furnished by Insured Person(s): Insured Person shall furnish all information requested on the Application and any additional information requested by the Company. The refusal of the Insured Person, the Insured Person’s Physician, Hospital or Service Provider to make all medical reports and records available to the Company could cause an otherwise valid claim or Application to be denied or the file to be closed due to lack of or limited reply from the Insured Person’s medical providers.Failure on the part of the Insured Person to maintain adequate documentation regarding travel history could cause an otherwise valid claim (where travel history is material to the benefitand claim) to be denied or the file to be closed. The Company has the option whether or not to consider medical information provided by friends / relatives of the Insured Person as valid for underwriting or claim administration. Assignment: The Insurance provided hereunder is not assignable, but benefits may be assigned in accordance with #5, Payment of Claims.

Excess Benefits: All coverages shall be in excess of all other valid and collectible insurance and shall apply only when such benefits are exhausted.

Other valid and collectible insurance for which benefits may be payable are insurance programs provided by:

  • 1.) Individual, group or blanket insurance or coverage;
  • 2.) Other prepayment coverage provided on a group or individual basis;
  • 3.) Any coverage under labor management trusteed plans, union welfare plans, employer organizational plans, employee benefit organization plans, or other arrangement of benefits for individuals of a group;
  • 4.) Any coverage required or provided by any statute, socialized insurance program; or
  • 5.) Any no-fault automobile insurance;
  • 6.) Any third party liability insurance

Monetary Limits: The monetary limits stated in this Certificate and the premium shall be in United States dollars. For services outside of the territorial limits of the United States, the exchange rate used to determine the amount of United States dollars to be paid is the exchange rate effective for the date the claims expense was incurred.

Subrogation: The Certificate has the right to full subrogation and reimbursement of any and all amounts paid by the Certificate to or on behalf of, an Insured Person, if the Insured person receives any sum of money from any person, plan or legal entity which is legally obligated to make payments arising out of any act or omission of any person whether a third party or another covered person under the Certificate, which directly or indirectly caused a physical or mental condition, in connection with which payment of any benefits under the Certificate to, or on behalf of, such Insured Person was made. The Certificate shall have a lien against such sum of money received from third parties or other persons described above or their insurers, or the insurer of the Insured Person, and shall be reimbursed therefrom. The Insured Person further agrees to notify other persons described above in writing, of the Certificate's subrogation and lien rights before the receipt of any payment from said parties or other persons.

The Insured Person shall be responsible for all expenses of recovery from such parties or other persons, including but not limited to, all attorneys' fees incurred in collection of suchpayments or payments by other persons, which fees and expenses shall not reduce the amount of reimbursement to the Certificate required of the Insured Person. The Insured Person agrees to reimburse the Certificate for any benefit paid hereunder, out of any monies recovered from such party or other persons as a result of judgment, settlement or otherwise, even though such monies are not characterized as amounts paid for medical expenses or claims. The Insured Person agrees to furnish such information and assistance, and to execute and deliver all necessary instruments, as the Company or its designee may request to facilitate the enforcement of these subrogation rights, including but not limited to the execution of a subrogation agreement prior to payments of benefits under the Certificate to, or on behalf of the Insured Person.

The Insured Person shall not release or discharge any party from his or her obligation to the Insured Person or the Certificate or take any other action which could impair the Certificate's subrogation rights. The Certificate's exercise of its rights to take whatever action it sees fit against any third party or other persons shall not affect the Insured Person's right to pursue other forms of recovery.

If the Insured Person or any one acting on his or her behalf has not taken action to push his or her rights against such parties or other persons to obtain a judgment, settlement or other recovery, the Company or its designee, upon giving thirty (30) days written notice to the Insured Person shall have the right to take such action in the name of the Insured Person to recover that amount of benefits paid under the Certificate; provided, however, that any action taken without the consent of the Insured Person shall be without prejudice to such Insured Person The Certificate's right to reimbursement as set forth herein shall be payable first from sums received from the parties or other persons and such reimbursement shall continue until the Insured Person's obligations hereunder to the Certificate are fully discharges, even though the Insured Person does not receive full compensation or recovery for his/her injuries, damages loss or debt. This right to subrogation pro tanto shall exist in all cases. If an Insured Person fails to comply with these requirements, the Insured Person shall not be eligible to receive any benefits, services or payments under the Certificate until there is compliance regardless of whether such benefits are related to the act or omission of such party or other persons.

Fraud and Misrepresentation: Any misstatement, concealment or fraud in the Applicant’s (or Applicant’s authorized representative) statements, either on the Application or on subsequent contact (including any claim submissions), whether in writing or otherwise, to the Company or its representatives, shall render this insurance null and void and all claims hereunder shall be forfeited. In addition, if any fraudulent means or devices are used by any Insured Person (or Applicant) or anyone acting on their behalf, this insurance shall be null and void and all claims hereunder shall be forfeited. 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"). The insurance benefits provided by this policy are stated in your policy documents and do not include any additional benefits required by the PPACA. The PPACA requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage. In certain circumstances penalties may be imposed on U.S. residents and citizens who do not maintain PPACA compliant insurance coverage. You should consult your attorney, insurance agent, or tax professional to determine if the PPACA's requirements are applicable to you.

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"). The insurance benefits provided by this policy are stated in your policy documents and do not include any additional benefits required by the PPACA. The PPACA requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage. In certain circumstances penalties may be imposed on U.S. residents and citizens who do not maintain PPACA compliant insurance coverage. You should consult your attorney, insurance agent, or tax professional to determine if the PPACA's requirements are applicable to you.

Benefit

SCHEDULE OF BENEFITS

All benefits listed in this Schedule of Benefits are in United States Dollar amounts. All Medical and Dental benefits are subject to the Deductible. All benefits are per person, per Injury or Illness, unless otherwise noted. No Coinsurance applies.

Plan Name

Inbound® USA-Basic

Plan type

Scheduled

Length of Coverage

5 days to 364 days

Ages

14 days to age 99

Benefit Period

180 Days

Medical Treatment Services

 

Medical Maximum Options (Per person, per Injury or Illness)

Ages 14 days to 69 years:

$50,000; $75,000; $100,000; $125,000;$150,000

Ages 70 to 99 years:

$50,000; $75,000; $100,000

Deductible Options (Per person, per Injury or Illness)

Ages 14 days to 69 years: $0; $50; $100

Ages 70 to 99 years: $100; $200

Hospital Room Board, including Laboratory Tests, X-Rays, Prescription Medication, Extended Care Facility and other Hospital Miscellaneous Expenses

Up to $1,000/day, 30 day maximum

Hospital Intensive Care Unit

Additional $500/day, 8 day maximum

Surgery (Inpatient Outpatient)

Up to $3,000

Anesthetist (Inpatient Outpatient)

Up to $500

Assistant Surgeon (Inpatient Outpatient)

Up to $500

Physician Non-Surgical Visits, including Urgent Care

(Inpatient Outpatient)

Up to $50/visit, 1/day,

30 visits maximum

Consulting Physician when requested by attending Physician

Up to $250

Private Duty Nursing

Up to $500

Pre-Admission Tests within 7 days of Hospital admission

Up to $750

Diagnostic Basic (X-ray Laboratory Tests)

Up to $500

Diagnostic Comprehensive (PET, CAT, MRI)

Up to $750

Hospital Emergency Room

Up to $250

Prescription Drugs

Up to $150 Per Period of Coverage

Outpatient Surgical Facility Day surgery miscellaneous, related to Outpatient scheduled Surgery performed at a Hospital or licensed Outpatient Surgery center; including the cost of the operating room, anesthesia, drugs and medicines and medical supplies.

Up to $750

Other Treatment Services

 

Ambulance Services

Up to $250

Initial Orthopedic Prosthesis/Brace

Up to $1,000

Durable Medical Equipment

Up to $1,200

Chemotherapy and/or Radiation Therapy

Up to $1,500

Dental Emergency - Accident Coverage

Up to $500

Dental Emergency - Sudden Relief of Pain*

Up to $500

Mental Nervous Disorder Substance Abuse

Same as any Illness

Physiotherapy (Inpatient Outpatient)

Up to $30/visit, 1/day, 12 visits maximum

Emergency Medical Evacuation

$100,000

Return of Mortal Remains

$20,000

Local Cremation / Burial

$5,000

Terrorism

$25,000

Incidental trips to Home Country*

$25,000

Common Carrier ADD

$25,000 per Insured Person

(aggregate limit of $125,000 per any one Accident)

International Travel Coverage*

Up to Medical Maximum

Acute Onset of Pre-Existing Conditions

Ages 14 days to 69 years: Up to $50,000

Ages 70 to 79 years: Up to $25,000

Age 80 and older: N/A

MEDICAL

Deductibles: Subject to Section 1.4, the Deductible is per person and per Injury or Illness. It is applied to Covered Expenses and must be paid by You prior to receiving payment or reimbursement of benefits under this Certificate. In no event will the Company's maximum liability exceed the amount set forth in the Schedule of Benefits.

Deductible

The Deductible is set forth in the Schedule of Benefits.

Medical Covered Expenses. Subject to the terms of the Certificate, the Company will reimburse You for Covered Expenses up to the amount shown in the Schedule of Benefits for the following medical Expenses that are incurred as the result of and within the Benefit Period. Payment for any Covered Expense will be no more than the amount shown in the Schedule of Benefits. The total payable for all Covered Expenses will be no more than the Medical Maximum per Illness or Injury. If a benefit is designated in the Schedule of Benefits, Covered Medical Expenses include:

(a) Hospital Room and Board:

(i) Daily semi-private room rate when Hospital confined;

(ii) General nursing care provided and charged for by the Hospital;

(iii) Hospital Miscellaneous Expenses: 1) While Hospital confined; or 2) for pre-admission expenses for being Hospital confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; x-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies.

(b) Intensive Care: Intensive Care is defined in Section 8.

(c) Surgery: Physician’s fees for Inpatient or Outpatient Surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits.

(d) Anesthetist Services: In connection with Inpatient or Outpatient Surgery.

(e) Assistant Surgeon: In connection with Inpatient or Outpatient Surgery.

(f) Physician’s Visits:

(i) When Hospital confined: Benefits are limited to one (1) Physician’s visit per day. Benefits do not apply when related to Surgery. Covered medical Expenses will be paid under the Inpatient benefit or under the Outpatient benefit for Physician’s visits, but not both.

(ii) Outpatient: Benefits are limited to one (1) Physician’s visit per day. Includes injections administered during visit. Benefits do not apply when related to Surgery or Physiotherapy. Covered medical Expenses will be paid under the Outpatient benefit or under the Inpatient benefit for Physician’s visits, but not both.

(g) Consultant Physician fees: When requested and approved by the attending Physician.

(h) Private Duty Nursing Services:

(i) Private duty nursing care only; and

(ii) While Hospital confined; and

(iii) Ordered by a licensed Physician; and

(iv) Medically Necessary.

General nursing care provided by the Hospital is not covered under this benefit.

(i) Pre-Admission Testing: Limited to routine tests such as complete blood count, urinalysis, and chest x-ray. If otherwise payable under the Certificate, major diagnostic procedures such as CAT scans, NMR’s, and blood chemistries will be paid as “Hospital Miscellaneous Expenses” under the “Hospital Room and Board” benefit.

(j) Diagnostic Basic: X-rays and laboratory tests (Outpatient)

(k) Diagnostic Comprehensive: PET, CAT, and MRI scans (Outpatient)

(l) Hospital Emergency Room (Outpatient): Only in connection with a Medical Emergency as defined in Section 8. Benefits will be paid for the use of the emergency room and supplies.

(m) Prescription Drugs (Outpatient)

(n) Outpatient Surgical Facility Day Surgery Miscellaneous: In connection with Outpatient day Surgery; excluding non-scheduled Surgery, and Surgery performed in a Hospital emergency room, trauma center, Physician’s office, or clinic. Benefits will be paid for services and supplies such as the cost of the operating room, laboratory tests and x-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies.

(o) Initial Orthopedic Prosthesis/Braces:

(i) When prescribed by a Physician; and

(ii) a written prescription accompanies the claim when submitted.

(p) Durable Medical Equipment: Durable Medical Equipment is defined in Section 8.

(q) Chemotherapy and/or Radiation Therapy.

(r) Mental and Nervous Disorder including Substance Abuse (Inpatient or Outpatient): The benefits and the maximum amounts are specified in the Schedule of Benefits. Benefits are limited to one (1) Physician’s visit per day.

(s) Physiotherapy (Inpatient Outpatient).

The exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 3.2.

Ambulance Services. The Company will reimburse You up to the amount set forth in the Schedule of Benefits for the Period of Coverage for local ambulance service from within the metropolitan area to the nearest Hospital having facilities required for Medically Necessary Treatment. Other than in an emergency, a licensed air ambulance transportation may be substituted for a ground ambulance if You are in a rural area and unreachable by ground ambulance. The exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 3.3.

Pre-Certification Requirements. Pre-certification is required in the United States only and for the following:

(a) Outpatient surgeries or procedures;

(b) Inpatient surgeries, procedures, or stays including those for rehabilitation;

(c) Diagnostic procedures including MRI, MRA, CT, and PET Scans;

(d) Chemotherapy;

(e) Radiation therapy;

(f) Physiotherapy (must include Physician’s recommendation and treatment plan); and

(g) Extended Care Facility.

To obtain pre-certification, You must:

(a) Contact Seven Corners Assist as soon as possible before the Expense is incurred;

(b) Comply with Seven Corners Assist’s instructions and submit any required information or documents; and

(c) Notify all Physicians, Surgeons, Hospitals, and other providers that this Insurance contains pre-certification requirements and request that they fully cooperate with Seven Corners Assist.

If You do not comply with the pre-certification requirements:

(a) Covered Expenses will be reduced by $500; and

(b) The Deductible will be subtracted from the remaining benefit amount.

Pre-certification does not guarantee coverage, payment, or reimbursement. Eligibility, coverage, and payment or reimbursement remains subject to all the terms, conditions, provisions, and exclusions herein.

For Inpatient stays of any kind in the United States, the Administrator initially will pre-certify a limited number of days of confinement. Notify all Physicians, Surgeons, Hospitals, and other providers that this Insurance requires them to receive prior approval for additional days of confinement following the pre-certification requirements.

Incidental Trips to Home Country. If the Period of Coverage is greater than thirty (30) days, the Company will reimburse You for Covered Expenses up to the amount set forth in the Schedule of Benefits for a new covered Injury or Illness that begins while You are on an incidental trip to Your Home Country. You must first depart Your Home Country before utilizing this benefit, and it does not apply to the final trip to Your Home Country. You may be required to provide proof of your travel intentions.

Additionally, this coverage will not apply:

(i) if the Illness began or Injury occurred while You were outside Your Home Country; or

(ii) for Pre-Existing Conditions.

Under this Section 3.5, You will receive five (5) days of medical coverage per month up to sixty (60) days for every three hundred sixty-four (364) days purchased in a policy. This coverage will apply separately for each three hundred sixty-four (364) day period, which means that any unused days of coverage from the prior three hundred sixty-four (364) day period(s) will not carry over to the any subsequent three-hundred sixty-four (364) day period, but, instead, you will start earning days of coverage over again. The exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 3.5.

The limit for this coverage is that amount shown on the Schedule of Benefits under “Incidental Trips to Home Country,” not that amount shown for “Medical Maximum Options.” The Deductible options set forth in Section 3.1 apply to this coverage and will be Your responsibility.

Acute Onset of Pre-Existing Condition(s). If you are a non-United States Resident, the exclusion set forth in Section 7(a) is waived for the eligible medical Expenses for the first Acute Onset of a Pre-Existing Condition(s) during the Period of Coverage up to the amount set forth in the Schedule of Benefits for eligible medical Expenses incurred in the United States. This waiver is subject to Your payment of your selected Deductible. This waiver does not include coverage for known, scheduled, required, or expected medical care, drugs, or Treatments existent or necessary prior to arrival in the United States and prior to the Effective Date of Coverage; coverage for Treatment for which You have traveled; or coverage for conditions for which travel was undertaken after Your Physician has limited or restricted travel.

Coverage ceases on the earliest of:

(i) the condition no longer being considered acute; or

(ii) your discharge from the Hospital.

Acute Onset of Pre-Existing Condition(s) is defined in Section 8. See the Schedule of Benefits for additional details.

DENTAL

Dental Emergency - Sudden Relief of Pain. If the Certificate has a Period of Coverage thirty (30) days or more, the Company will reimburse You up to the amount set forth in the Schedule of Benefits for Covered Expenses exceeding the Deductible for emergency Treatment for the relief of pain to Sound Natural Teeth. The exclusions set forth in Section 7 apply to the coverage provided by this Certificate under this Section 4.1.

Dental Emergency - Accident Coverage. The Company will reimburse You up to the amount set forth in the Schedule of Benefits for Covered Expenses exceeding the Deductible for emergency Treatment to repair or replace Sound Natural Teeth damaged as the result of an Accidental Injury caused by external contact with a foreign object. Coverage does not apply if You break a Sound Natural Tooth while eating or biting into a foreign object. Additionally, the exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 4.2.

EMERGENCY SERVICES AND ASSISTANCE

Emergency Medical Evacuation. The Company will pay transportation and related medical Expenses incurred during such transportation up to the amount set forth in the Schedule of Benefits if any covered Injury or Illness commences while You are outside Your Home Country during the Period of Coverage and results in Your Medically Necessary Emergency Medical Evacuation. All transportation arrangements must be by the most direct and economical route. The Emergency Medical Evacuation must be arranged by Seven Corners Assist in consultation with Your local attending Physician. Failure to utilize Seven Corners Assist will result in the denial of benefits. Additionally, the exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 5.1.

Return of Mortal Remains. Provided that You have not elected the benefit provided under Section 5.3, the Company will pay up to the amount set forth in the Schedule of Benefits for the reasonable expenses incurred for embalming, a minimally-necessary container appropriate for transportation, shipping costs, and the necessary government authorizations to return Your remains to Your Home Country if You die while outside Your Home Country during the Period of Coverage from an Illness or Injury covered under this Insurance. This benefit applies regardless of whether the death is related to a Pre-Existing Condition. The return of mortal remains must be arranged by Seven Corners Assist. Failure to utilize Seven Corners Assist will result in the denial of benefits. Additionally, the exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 5.2.

Local Burial or Cremation. Provided that You have not elected the benefit provided under Section 5.2, the Company will pay up to the amount set forth in the Schedule of Benefits for the reasonable expenses incurred for preparation and either Your local burial or Your cremation if You die while outside Your Home Country during the Period of Coverage from an Illness or Injury covered under this Insurance. This benefit applies regardless of whether the death is related to a Pre-Existing Condition. This Insurance does not include the expenses for the religious practitioners performing the service, flowers, music, food, or beverages. The local burial and cremation must be arranged by Seven Corners Assist. Failure to utilize Seven Corners Assist will result in the denial of benefits. Additionally, the exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 5.3.

Terrorist Activity. The Company will reimburse You up to the amount set forth in the Schedule of Benefits for Your Covered Expenses incurred resulting from Terrorist Activity provided:

(i) You have no direct or indirect involvement in the Terrorist Activity;

(ii) the Terrorist Activity is not in a country or location where the United States government has issued a Level 3 Terrorism, Level 3 Civil Unrest, or any Level 4 Travel Advisory or the appropriate authorities of either Your Host Country or Your Home Country have issued similar warnings, any of which have been in effect within the six (6) months prior to Your date of arrival; and

(iii) You departed the country or location following the date a warning to leave that country or location is issued by the United States government or the appropriate authorities of either Your Host Country or Your Home Country.

OTHER COVERAGES AND SERVICES

Travel Assistance Services. Upon enrollment, You are eligible to use any of the assistance services provided by Seven Corners Assist. These services are available 24 hours per day, 365 days per year. Multilingual personnel, Physicians, and nurses are on staff and can assist with, among other things, emergency situations and locating local facilities.

Common Carrier Accidental Death and Dismemberment. The Company will pay an indemnity up to the amount set forth in the Schedule of Benefits if You die as the result of an Injury suffered from an Accident while You were traveling on a Common Carrier. Death must occur during the Period of Coverage and while You are riding as a passenger on a Common Carrier and not as a pilot, operator, or member of the crew. The benefit will be paid to the person determined by application of the relevant provisions of Section 6.2.

The total amount payable under this Section 6.2 when there are multiple Insured Persons covered by the Certificate is the Aggregate Limit as set forth in the Schedule of Benefits. If the total of such indemnity exceeds the Aggregate Limit, the Company will not be liable to any Insured for a greater proportion of such Insured’s indemnity afforded by the Common Carrier Accidental Death and Dismemberment Benefit than their proportionate share.

Additionally, the exclusions set forth in Section 7 apply to the coverage provided by the Certificate under this Section 6.2.

International Travel Coverage. An insured person may travel to additional countries, other than the United States, up to a maximum of fourteen (14) days. You must purchase a minimum of thirty (30) days of coverage to be eligible for this benefit. International travel coverage does not include travel back to the Insured Person’s Home Country, and it does not extend after your current Expiration Date of Coverage. International travel must be utilized during your current Period of Coverage. The Trip must originate in the United States.

EXCLUSIONS

Unless otherwise specifically provided for therein, the coverage provided by the Certificate under Sections 3.2, 3.3, 3.5, 3.6, 4.1, 4.2, 5.1 through 5.4, 6.2, and 6.3, excludes Expenses that are for, resulting from, related to, or incurred for the following:

(a) Pre-Existing Condition(s) except as waived under Sections 3.6, 5.2 and 5.3 above.

(b) Claims not received by the Company or Administrator within ninety (90) days of the date of service;

(c) Treatment that is Investigational, Experimental, or for research purposes;

(d) Treatment, services, or supplies that are not administered by or under the supervision of a Physician or Surgeon and products that can be purchased without a Physician’s or Surgeon’s prescription;

(e) Routine physicals, inoculations, or other examinations or tests conducted when there is no objective indications or impairments in normal health;

(f) Chiropractic care or acupuncture;

(g) Services, supplies, medications, testing, or Treatment prescribed, performed, or provided by a Relative or Immediate Family Member;

(h) False teeth, dentures, dental appliances, dental expenses, normal ear or hearing tests, hearing aids, hearing implants, eye refractions, eye examinations for prescribing corrective lenses or eye-

glasses unless caused by Accidental Injury, eyeglasses, contact lenses, or eye surgery when the primary purpose is to correct nearsightedness, farsightedness, or astigmatism;

(i) Replacement of artificial limbs, eyes, larynx, and orthotic appliances;

(j) Custodial Care, Educational or Rehabilitative Care, or any Treatment in any establishment for the care of the aged;

(k) Vocational, occupational, sleep, speech, recreational, art, or music therapy;

(l) Pregnancy, Illness or complications from Pregnancy, childbirth, abortion, miscarriage including that resulting from an Accident, postnatal care, preventing conception or childbirth, artificial insemination, infertility, impotency, sexual dysfunction, or sterilization or reversal thereof;

(m) Sleep apnea or other sleep disorders;

(n) Mental and Nervous Disorders unless specifically covered herein, Rest Cures, learning disabilities, attitudinal disorders, or disciplinary problems;

(o) Congenital abnormalities and conditions arising out of or resulting therefrom.

(p) Temporomandibular joint;

(q) Occupational Diseases;

(r) Exposure to non-medical nuclear radiation or radioactive materials;

(s) Sexually transmitted diseases, venereal diseases, and conditions and any consequences thereof;

(t) Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or the Human Immunodeficiency Virus (HIV);

(u) Human organ or tissue transplants.

(v) Exercise programs whether prescribed or recommended by a Physician or therapist;

(w) Weight reduction programs or the surgical Treatment of obesity including, but not limited to, wiring of the teeth and all forms of intestinal bypass Surgery;

(x) Cosmetic or plastic Surgery including deviated nasal septum; modifications of Your physical body intended to improve Your psychological, mental, or emotional well-being including, but not limited to, sex-change Surgery;

(y) Acne, moles, skin tags, disease of sebaceous glands, seborrhea, sebaceous cyst, unspecified disease of the sebaceous glands, hypertrophic and atrophic conditions of skin, nevus;

(z) Hazardous Activities;

(aa) Injuries sustained while participating in professional Athletics, amateur Athletics, or interscholastic Athletics including, but not limited to, events, games, matches, practice, training camps, sport camps, conditioning, and any other activity related thereto and excluding non-competitive, recreational, or intramural activities;

(bb) Abuse, misuse, illegal use, overuse, or being under the influence of alcohol, drugs, chemicals, or narcotic agents unless administered under the advice of a Physician and taken in accordance with the proper dosing as directed by the Physician;

(cc) Suicide or any attempt thereof; self-destruction or any attempt thereof; or any intentionally self-inflicted Injury or Illness;

(dd) Terrorist Activity except as provided under Section 5.4; War, Hostilities, or War-Like Operations;

(ee) Commission of a criminal offense or any other criminal or illegal activity as defined by the local governing body;

(ff) You unreasonably fail or refuse to depart a country or location following the date a warning to leave that country or location is issued by the United States government or similar warnings issued by other appropriate authorities of either Your Host Country or Your Home Country;

(gg) Service in the military, naval, coast guard, or air service of any country or while on duty as a member of a police force or unit;

(hh) Treatment paid for or furnished under any other individual, government, or group policy or Expenses incurred at no cost to You;

(ii) You while in Your Home Country unless covered under Section 3.5;

(jj) Conditions for which travel was undertaken to seek Treatment after Your Physician has limited or restricted travel;

(kk) Travel accommodations;

(ll) Injury sustained while You are riding as a pilot, student pilot, operator, or crew member, in or on, boarding or alighting, from any type of aircraft;

(mm) Injury sustained while You are riding as a passenger in any aircraft (i) not having a current and valid Airworthy Certificate and (ii) not piloted by a person who holds a valid and current certificate of competency for piloting such aircraft;

(nn) Flying in any aircraft being used for acrobatic or stunt flying, racing, endurance tests, rocket-propelled aircraft, crop dusting or seeding or spraying, firefighting, exploration, pipe or power line inspection, any form of hunting or herding, aerial photography, banner towing, or any experimental purpose;

(oo) Participating in contests of speed or riding or driving in any type of competition; and

(pp) Charges incurred for treatment or surgeries which are Experimental/Investigational, or for research purposes; expenses which are non-medical in nature, expenses for Custodial Care, vocational, speech, recreational or music therapy.

Acute Onset of a Pre-Existing Conditions

Sudden and unexpected outbreak or recurrence of a Pre-Existing Condition(s) that occurs spontaneously and without advanced warning either in the form of Physician recommendations or symptoms and requires urgent care. The Acute Onset of a Pre-Existing Condition(s) must occur after the Effective Date of Coverage and prior to the age shown in the Schedule of Benefits. Treatment must be obtained within twenty-four (24) hours of the sudden and unexpected outbreak or recurrence. A Pre-Existing Condition that is Congenital or that gradually becomes worse over time is not an Acute Onset of a Pre-Existing Condition. A Pre-Existing Condition will not be considered an Acute Onset of a Pre-Existing Condition(s) if, during the thirty (30) days prior to the acute event, You had a change in prescription or Treatment for a diagnosis related to the acute event. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs, or Treatments existent or necessary prior to arrival in the United States and prior to the Effective Date of Coverage.

Acute Onset of Pre-Existing Condition(s)

If you are a non-United States Resident, the exclusion set forth in Section 7(a) is waived for the eligible medical Expenses for the first Acute Onset of a Pre-Existing Condition(s) during the Period of Coverage up to the amount set forth in the Schedule of Benefits for eligible medical Expenses incurred in the United States. This waiver is subject to Your payment of your selected Deductible. This waiver does not include coverage for known, scheduled, required, or expected medical care, drugs, or Treatments existent or necessary prior to arrival in the United States and prior to the Effective Date of Coverage; coverage for Treatment for which You have traveled; or coverage for conditions for which travel was undertaken after Your Physician has limited or restricted travel.

Coverage ceases on the earliest of:

(i) the condition no longer being considered acute; or

(ii) your discharge from the Hospital.

Acute Onset of Pre-Existing Conditions

 

Ages 14 days to 69 years

Up to $50,000

Ages 70 to 79 years

$25,000

Age 80 and older

N/A

Coverage may be continued if the initial Period of Coverage is less than the Maximum Period of Coverage. If You elect to extend Your Trip beyond the initial Period of Coverage, You may extend the applicable Period of Coverage by a minimum of five (5) days and up to three hundred sixty-four (364) days at a time provided that the total Period of Coverage may not exceed the Maximum Period of Coverage. Upon such extension and receipt of the appropriate Plan premium and applicable fee charged for each extension, the original Certificate’s Expiration Date of Coverage will be extended to the new Expiration Date of Coverage. For Inbound® USA Basic, the original Effective Date of Coverage will be used to calculate Your Deductible; to determine whether maximum coverage amounts as set forth in the Schedule of Benefits have been obtained; and to determine any Pre-Existing Conditions. For Inbound® USA Choice and Elite Plans, a new Deductible will apply beginning the 365th day and beginning again on the 729th day, if applicable, during the Period of Coverage, but the original, beginning Effective Date of Coverage (day 1) will continue to be used to determine whether maximum coverage amounts as set forth in the Schedule of Benefits have been obtained and to determine any Pre-Existing Conditions.

Extensions, if offered by the Company, will be subject to the definitions, benefits, and conditions in force at the time of each renewal

We will refund your payment if we receive your written request for a refund before your effective date of coverage. If your request is received after your effective date, the unused portion of the plan cost may be refunded minus a $25 cancellation fee, if you have not submitted any claims to Seven Corners.

Notice of Claim. Written notice of claim must be given to the Company within ninety (90) days after the occurrence or commencement of any Disablement covered by the plan. Notice given by or on behalf of the claimant to the Administrative Offices of the Company or to any authorized agent of the Company, with information sufficient to identify You shall be deemed notice to the Company.

 Claim Forms. The Company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing Proofs of Loss. If such forms are not furnished within fifteen (15) days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of the plan as to Proof of Loss upon submitting, within the time fixed in the Certificate for filing Proofs of Loss, written proof covering the occurrence, the character, and the extent of the Disablement for which claim is made.

Proof of Loss. Written Proof of Loss must be furnished to the Company at its said office in case of claim for loss for which this Certificate provides any periodic payment contingent upon continuing loss within ninety (90) days after the termination of the period for which the Company is liable and in case of claim for any other loss within ninety (90) days after the date of such loss. Failure to furnish such Proof of Loss within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give Proof of Loss within such time, provided such Proof of Loss is furnished as soon as reasonably possible. The Company at its option may pend resolution and adjudication of submitted claims and/or deny coverage for Proof of Loss submitted thereafter, or for incomplete Proof of Loss and/or failure to submit Proof of Loss.

Time of Payment of Claims. Indemnities payable under the Certificate for any loss other than loss for which the Certificate provides any periodic payment will be paid immediately upon receipt of due written Proof of Loss. Subject to due written Proof of Loss, all accrued indemnities for loss for which the Certificate provides periodic payment will be paid at the expiration of each four (4) weeks during the continuance of the period for which the Company is liable, and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.

Payment of Claims. Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to Your estate. Any other accrued indemnities unpaid at Your death may, at the option of the Company, be paid either to such beneficiary or to such estate. All other indemnities will be payable to You. If any indemnity of the Certificate shall be payable to Your estate or to an Insured Person who is a under the age of eighteen (18) or otherwise not competent to give a valid release, the Company may pay such indemnity, up to an amount not exceeding $1,000, to any Relative by blood or connection by marriage of the Insured Person who is deemed by the Company to be equitably entitled thereto. Any payment made by the Company in good faith pursuant to this provision shall fully discharge the Company to the extent of such payment. Subject to any written direction of You, all or a portion of any indemnities provided by this Certificate on account of Hospital, nursing, medical or Surgical service may, at the Company's option and unless You request otherwise in writing not later than the time for filing Proof of Loss, be paid directly to the Hospital or person rendering such services, but it is not required that the service be rendered by a particular Hospital or person.

Appeal of Claims. If the Company denies all or any part of a claim, You will have a maximum of two (2) appeals for review of the claim and determination, and You must file two (2) appeals before bringing any legal action hereunder. You will have sixty (60) days from the date of the notice of denial within which to file an appeal. You may submit written comments, documents, records, or other information with the notice of appeal. The Company will respond in writing to an appeal as soon as reasonably possible but, in any event, within ninety (90) days from receipt of the notice of appeal.

Complaints. Initial inquiries or complaints are to be addressed to the Administrator. If You are not satisfied with the way an inquiry or complaint has been managed by the Administrator, You may request in writing to the Complaints & Advisory Department of the Company a review of the case without prejudice to the Insured Person’s rights.

Complaints

Fidentia House

Walter Burke Way

Chatham Maritime

Chatham

Kent

ME4 4RN

Email: complaints@lloyds.com

Tel: +44 (0)20 7327 5693.

Claims must be submitted within 90 days of the date of service.

See Section 9 for claims procedures or visit sevencorners.com/claims

for claim forms and more information.

Claims may be submitted as follows:

Email: claims@sevencorners.com

Online: sevencorners.com/myaccount

Fax: 317-575-2256

For additional assistance with claims, contact Seven Corners:

Toll-free: 800-335-0477

Worldwide: 317-575-2652

Email: customerservice@sevencorners.com