The Schedule of Benefits is a summary outline of the benefits covered under this insurance Plan. The benefits are divided into three sections; Medical Expense Benefits, Non-Medical Expense Benefits, and Accidental Death & Dismemberment Benefits. Please read the Description of Benefits sections for full details. All benefits described are subject to the definitions, exclusions and provisions.

ELIGIBLE PERSONS

Eligible Person is an individual who meets all the requirements of one of the covered Classes shown below: Class 1

A registered full time undergraduate or a graduate student attending classes who is a minimum age of 12 years and maximum of 40 years;

1. Student must have a current passport and be travelling outside their Home Country, and
2. Student must have a valid F, M, or Q visa. F1 visa holder on OPT are not eligible.

Or

A J1 valid visa holder who is outside their Home Country and is actively engaged in an educational activity and who is a minimum age of 12 years and a maximum age of 40 years, if you are one of the following:

1. Undergraduate student registered for and attending classes on a full-time basis; or
2. Graduate student; or
3. Scholar or researcher who is invited by an educational organization; or
4. Student involved in education, educational activities, or research related activities.

Class 2

The spouse or domestic partner of a Class 1 Insured Person.

Class 3

The Dependent child(ren) of a Class 1 Insured Person.

The Policyholder is the Fairmont Specialty Trust, hereinafter shall be referred to as the “Trust”.

The Insurer, Crum & Forster, SPC, hereinafter shall be referred to, sometimes collectively, as the “Insurer”, “We” “Us”, “Our” or “Company”.

The declarations of the Insured Person in the application serve as the basis for participation in the Trust. If any information is incorrect or incomplete, or if any information has been omitted, the insurance coverage may be rescinded or terminated. Any references in this Summary of Benefits to the Insured Person expressed in the masculine gender shall be interpreted as including the feminine gender whenever appropriate.

No change in the Master Policy will be valid until approved by one of Our executive officers. This approval must be endorsed on or attached to the Master Policy. No agent may change the Master Policy or waive any of its provisions.

This Plan is an international health insurance policy issued to the Trust. This insurance shall be governed by the Laws of the Cayman Islands If any dispute arises as to the interpretation of this document, the English version shall be deemed to be conclusive and taking precedence over any other language version of this document.

Notwithstanding any other terms under this Plan, the Insurer shall not provide coverage nor make any payments or provide any service or benefit to any Insured Person, beneficiary, or third party who may have any rights under this Plan to the extent that such cover, payment, service, benefit, or any business or activity of the Insured Person would violate any applicable trade or economic sanctions law or regulation.

                ELIGIBILITY

1.1  Eligible Classes

International full-time students (as defined by the educational institution) enrolled in an associate, bachelor, master, or Ph.D. program at a university or other accredited higher education institution, or a scholar, researcher, teacher, or student involved in educational activities outside of their Home Country. The full-time requirement is waived for summer if the student was enrolled in this Plan as a full-time student in the immediately preceding spring term. Students must actively attend classes or the program they have enrolled. Home study, correspondence, and online courses do not fulfill the Eligibility requirements that the student actively attend class.

The Insurer has the right to investigate Eligibility status and attendance records to verify Eligibility requirements are met. If it is discovered the Eligibility requirements are not met, the insurance coverage will be terminated.

1.2  Persons Eligible to be an Insured Person

The Insured Person on this Plan who is an Eligible Person as identified in the Schedule of Benefits, a Non-United States Citizen travelling outside their Home Country and travelling to the United States and has their true, fixed and permanent home and principal establishment outside of the United States and holds a current a nd valid passport, and for whom proper Premium payment has been made when due.

Insured Persons are those persons described as an Eligible Class.

Students who are United States citizens or permanent legal residents of the United States are not eligible for coverage.

1.3  Eligible Dependents

Coverage can be extended to the following members who are traveling with the student who is the Insured Person. Insured Dependents may include:

• The spouse or domestic partner up to age 40,
• Dependent children up to age 19, if single. Dependent children include the Insured Person’s natural children, legally adopted children, and stepchildren.

Dependents who are United States citizens or permanent legal residents of the United States are not eligible for coverage.

1.4  Application and Effective Date

The Insured Person’s coverage becomes effective on the Effective Date shown on the Medical Identification Card. Coverage under the Plan ends on the earlier of:

On the expiration date of the insurance coverage. However, if an Insured Person’s return is delayed due to

unforeseeable circumstances beyond their control, the insurance coverage will be extended until such trip can be completed, but no later than seven days from the original insurance coverage expiration, or

• If medical evacuation was necessary, upon the Insured Person’s evacuation to the Home Country.
• Termination of coverage of the Insured Person also terminates coverage for Dependents.

Note: The minimum period of insurance must be the entire duration the Insured Person actively attends classes.

1.5  Pre-Existing Conditions Limitations

For Plans that include a Waiting Period for Pre-Existing Conditions, the Waiting Period will be reduced by the total number of months that the Insured Person provides documentation of continuous coverage under prior Qualifying Insurance Coverage which provided benefits similar to this Plan provided the coverage was continuous to a date within 63 days prior to the Insured Person’s Effective Date.

1.6  Addition of a Newborn Baby or Legally Adopted Child

Born Under a Pregnancy Covered by the Maternity Benefit or Adopted as of the Date of Birth:

Newborn babies will be covered as a Dependent, for full coverage according to the terms of the Plan, regardless of medical status from the date of birth provided:

• Written notification is made to the Insurer within 31 days of the date of birth, or in the case of an adopted child, a copy of the legal adoption papers is required. The newborn child shall be accepted from the date of birth
• The newborn baby will be enrolled for the same coverage as the Insured Person.

Any request received beyond the 31-day notification period shall result in coverage only being effective from the date of notification and provisional coverage will be applied for the first 31 days of life, up to a $5,000 maximum. Coverage is not guaranteed and is subject to submission of a medical statement.

Born When an Insured Person is Not Covered by the Maternity Benefit: Newborn babies, that are born, and the Insured Person is not covered by the maternity benefit under this Plan, may be covered subject to the following:

• The Insured Person will provide written notification to the Insurer (Official Copy of Birth Certificate), and
• A Health Statement must be submitted detailing the medical history of the child,
• Coverage will become effective as of the date of notification, provided the Insurer has approved the Health Statement, Coverage is not guaranteed and is based upon the health of the newborn baby,
• Any applicable Pre-existing condition limitation will apply.

1.7  Addition of a Legally Adopted Child After the Date of Birth

A child adopted after the date of birth may be covered providing the following applies:

• The child must be up to 19 years old, and
• The Insured Person will provide written notification to the Insurer (an official copy of the legal adoption papers is required with the notification), and
• A Health Statement must be submitted detailing the medical history of the child.

Coverage will be contingent based upon the terms and conditions of the Plan. Additionally,

• Coverage will become effective as of the date of notification, and
• Any applicable Pre-Existing Condition limitation will apply.

1.8  Extended Coverage

The Extended Coverage benefit is available to newly enrolled students who arrive in the United States prior to the beginning of the first term of study in the United States, or Insured Persons who have completed their final term of study in the United States and are preparing to return to the Home Country. The Extended Coverage benefit provides up to 60 days of additional coverage.

Extended Coverage does not apply to Insured Persons who are continuing their studies or returning to studies in the United States whether at the same or different institutions.

Newly-Enrolled and Arriving Students

In order to be eligible for the Extended Coverage Benefit and before any benefits will be paid:

1. A newly enrolled and arriving student must have enrolled in full-time studies at the higher education institution, and
2. All Premiums must be paid.

Coverage under the Extended Coverage Benefit will become effective on the later of:

1. 60 days prior to the beginning of the term, or, if later,
2. On the first day the qualifying, newly enrolled and arriving student arrives in the United States.

Students Concluding their Studies

An Insured Person may extend coverage for a maximum of 60 days, provided the Period of Insurance does not exceed 365 days, while remaining in the United States following graduation or completion of an educational program. To be eligible for the Extended Coverage benefit and before any benefits will be paid:

1. The Insurer must receive the request for Extended Coverage prior to the termination of the Insured Person’s coverage, and
2. All Premiums must be paid.

Coverage under the Extended Coverage Benefit will terminate on the earlier of:

1. 60 days following the Insured Person’s graduation or completion of an educational program, or
2. The date of departure from the United States.

Dependents of Insured Persons who are covered under the Extended Coverage benefit may also continue coverage under the same terms and conditions as the Insured Person.

Extended Coverage for Short-Term Programs

In the event the Insured Person’s entire program of study is less than 60 days, the applicable Extended Coverage benefit will be limited to seven days. All other Extended Coverage benefit provisions will apply as indicated herein.          

                         MEDICAL EXPENSE BENEFIT DESCRIPTIONS

THE FOLLOWING PROVIDES AN EXPLANATION OF THE BENEFITS OFFERED BY THE INSURER. PLEASE REFER TO THE SCHEDULE OF BENEFITS FOR THE SPECIFIC BENEFITS COVERED UNDER THIS PLAN OF INSURANCE.

All benefits provided under this Plan for a covered Illness or Injury must be:

• Ordered or recommended by a Physician and under the scope of the Physician’s licensing ,
• Medically necessary, and
• Delivered in an appropriate medical setting.

1.9  HOSPITALIZATION AND INPATIENT BENEFITS

1.9.a  Accommodations

Benefits are provided for room and board, special diets, and general nursing care. All charges more than the allowable semi-private room rate are the responsibility of the Insured.

Benefits are also provided for treatment in the Intensive Care or Coronary Care Unit if it is the most appropriate place for the Insured to be treated, the care provided is an essential part of the Insureds treatment, and the care provided is routinely required by patients suffering from the same type of Illness or Injury or receiving the same type of treatment.

The Insurer will pay costs if:

Treatment is Medically Necessary for the Insured Person to be treated on an Inpatient or Daycare basis, The stay in the Hospital is for a medically appropriate period of time, and

The treatment received is provided or managed by a Physician or specialist

Not Covered Under this Benefit

Inpatient Hospital Confinements primarily for purposes of receiving non-acute, long term Custodial Care, respite care, chronic maintenance care, or assistance with Activities of Daily Living (ADL), are not eligible expenses.

Expense for items that are provided solely for personal comfort or convenience such as television, private rooms, housekeeping services, guest meals and accommodations, special diets, telephone charges, and take -home supplies are not covered.

1.9.b  Medical Treatment, Medicines, Laboratory, Diagnostic Tests, and Hospital Miscellaneous Expense Miscellaneous expenses charged by a Hospital or ambulatory surgical center for Outpatient surgery. Miscellaneous expenses include, but are not limited to: X-ray, laboratory, in-Hospital physiotherapy, orthopedic appliances, pre- admission tests, and all other necessary charges, other than room and board, for services received during a Hospital stay.

1.9.c  Inpatient Consultation/Visit by a Physician or Specialist

Benefits are provided for the reimbursement of one Physician visit per day while the Insured Person is a patient in a Hospital or Extended Care Facility. Visits that are part of normal preoperative and postoperative care are covered under the surgical fee and Insurer will not pay separate charges for such care. If Medically Necessary, the Insurer may elect to pay more than one visit of different Physicians on the same day if the Physicians are of different specialties. The Insurer will require submission of records and other documentation of the Medical Necessity for the intensive services.

1.9.d  Pre-Admission Testing

Benefits are provided for any service related to an Insured Person’s planned Inpatient Admission or same day surgery that is performed on the day of, or within the period specified in the Schedule of Benefits prior to the day of, an Insured Person’s planned Inpatient Admission or same day surgery service.

Pre-Admission Testing services are considered related to an Inpatient Admission or same day surgery if the Outpatient principal diagnosis is similar to, or the same as, the Inpatient or same day surgery diagnosis.

1.9.e  Extended Care, Skilled Nursing Facility and Inpatient Rehabilitation

Benefits are provided for an Inpatient Confinement and services provided in an approved Extended Care Facility following, or in lieu of, an Admission to a Hospital as a result of a covered Illness or Injury. Care provided must be at a skilled level and is payable in accordance with the current Schedule of Benefits. Coverage for Confinement is subject to Insurer approval. Covered services include the following:

• Skilled nursing and related services on an Inpatient basis for patients who require medical or nursing care

for a covered Illness. A Confinement includes all approved Extended Care Facility Admissions not separated by at least 180 days.

• Rehabilitation for patients who require such care because of a covered Illness or Injury.

Not Covered Under this Benefit

Intermediate, custodial, rest and homelike care services will not be considered skilled and are not covered.

1.10   OUTPATIENT BENEFITS

1.10.a                 Physician Visit or Consultation by a Specialist

Benefits are provided for medical visits to a Physician or Specialist, in their office, if Medically Necessary. Benefits are limited to one visit per day per Insured Person. The Insurer may elect to pay more than one visit to different Physicians on the same day if the Physician or Specialist are of different specialties.

1.10.b                 Diagnostic Testing

Benefits are provided for diagnostic testing including MRI, ultrasound, and other specialized testing to diagnose an Illness or Injury.

1.10.c                  Advanced Medical Imaging

Benefits are provided for Medically Necessary advanced imaging recommended by a Physician or a Specialist to diagnose or treat an Illness or Injury. This includes;

• Magnetic Resonance Imaging (MRI),
• Computed tomography (CT), and
• Positron Emission Tomography (PET).

1.10.d                 Therapeutic Services

Benefits are provided for Medically Necessary therapeutic services rendered to an Insured Person as an Outpatient of a Hospital or Provider’s office. Services must be pursuant to a Physician’s written treatment plan, which contains short- and long-term treatment goals and is provided to Insurer for review. The following services must either:

• Produce significant improvement in the Insured Person’s condition in a reasonable and predictable period of time; and

• Be of such a level of complexity and sophistication, and the condition of the patient must be such that the required therapy can safely and effectively be performed; or
• Be necessary to the establishment of an effective maintenance program.

1.11   SURGICAL BENEFITS

1.11.a                 Surgical Services

Benefits are provided for covered surgical services received in a Hospital, outpatient facility, daycare treatment facility, Physician’s office, or other approved facility. Surgical services include the surgeon’s fee, use of operation room and recovery room, operative and cutting-procedures, treatment of fractures and dislocations, surgical dressings, and other Medically Necessary services.

1.11.b                 Anesthesia Services

Benefits are provided for the service of an anesthesiologist, other than the operating surgeon or assistant, who administers anesthesia for a covered surgical or obstetrical procedure.

1.12   EMERGENCY BENEFITS

1.12.a                 Emergency Room

Benefits are provided for a Medical Emergency when incurred in a Hospital’s emergency room. The Insurer retains the right to deem a true Medical Emergency. Admission to the Hospital is not required for benefit consideration. Within the United States, use of the emergency room for non-emergency services may result in higher Out-of- Pocket costs to the Insured Person.

1.12.b                 Emergency Ground Ambulance Services

Benefits are provided for Medically Necessary emergency ground ambulance transportation to the neares t Hospital able to provide the required level of care. This includes transporting the Insured Person from the scene of an Accident or Illness to a Hospital, from one Hospital to another, or from the Insured Person’s home to a Hospital.

Not Covered Under this Benefit

The use of ambulance services for the convenience of the Insured Person will not be considered a covered service.

1.12.c                  Emergency Dental

Benefits are provided for Emergency Dental treatment and restoration of sound natural teeth required as a result of an Accident. All treatment must begin within 72 hours of the Accident.

Not Covered Under this Benefit

Routine dental treatment is not covered. Damage to teeth caused by chewing foods or a toothache, does not qualify under this benefit.

1.12.d                 Palliative Dental Care

Benefits are provided for pain relief treatment to natural teeth or gums for an eligible palliative dental condition. Benefits are payable in accordance with the Schedule of Benefits.

1.13   MATERNITY CARE

The following Maternity Care benefits are covered and are applicable to any condition related to pregnancy: prenatal care, childbirth, postnatal care, and miscarriage.

Maternity Care benefits are only available to the primary Insured Person or Spouse.

Not Covered under this Benefit

Maternity Care benefits as defined above are not covered for any of the following:

• an insured Dependent daughter,
• a pregnancy resulting from the use of services, medications, or treatment used to commonly treat infertility,
• an individual acting as a surrogate.

1.13.a                 Physician and Obstetrical Services

Benefits are provided for the following Maternity Care related benefits:

• Obstetrical and other services rendered in a licensed Hospital or approved birthing center, including anesthesia, delivery, Medically Necessary C-section, prenatal and postnatal care for any condition related to pregnancy, including but not limited to childbirth and miscarriage;
• All prenatal and postnatal Physician’s office visits, laboratory and diagnostic testing; and
• Prenatal vitamins are covered during the term of the pregnancy only, if prescribed by a Physician.

Not Covered Under this Benefit

Elective C-sections are not covered.

1.13.b                 Newborn Infant Care Services

Benefits are provided for Hospital nursery services and medical care provided by the attending Physician for newborn infants in the Hospital are covered. Such services include but are not limited to general exams, immunizations, hearing tests, blood test for Phenylketonuria (PKU), and circumcision. Charges for Hospital nursery services and professional services for the newborn infant are covered separately from the mother’s Maternity benefits and are subject to satisfaction of the Individual Deductible and Coinsurance. Refer to Addition o f a Newborn Baby.

1.13.c                  Complications of Pregnancy

Benefits are provided for health complications to the mother as a result of a pregnancy, premature birth, and birth anomalies. Such conditions are not subject to the Maximum Benefit under Maternity Care, if one is shown on the Schedule of Benefits.

1.14   OTHER BENEFITS (INPATIENT/OUTPATIENT)

1.14.a                 Elective Abortion

Benefits are provided for the voluntary termination of a pregnancy that is covered under this Plan, if performed at a licensed facility and meets the guidelines of the state where performed.

1.14.b                 Mental Health Benefits

Benefits are provided for both Inpatient mental health treatment in a Hospital or approved facility and for Outpatient mental health treatment. A Physician, licensed clinical psychologist, social worker, or licensed professional counselor must provide all mental health care services. Treatment must be provided for a psychiatric disease identified in the most recent edition of the American Psychiatric Association Diagnostic and Statistical Manual or the International Classification of Diseases.

Not Covered Under this Benefit

Non-medical counseling services including but not limited to addictive behavior counseling, marriage and family counseling, educational counseling, aptitude testing, educational testing and services are not covered under this benefit.

1.14.c                  Preventive Care and Annual Exams

Newborn Wellness: Benefits are provided for well-child routine medical exams, health history, development assessments, immunizations, and age-related diagnostic tests covered up to the age of 12-months.

Child/Adult Wellness: Benefits are provided for routine physical examinations, immunizations for infectious diseases as recommended by the Center for Disease Control and preventive medical attention.

1.14.d                 Homeopathic Care and Acupuncture

Benefits are limited to the following:

• Acupuncture, homeopathy, and Traditional Chinese Medicine, where such are provided as treatment for an Illness covered under this Plan,
• Treatment is covered only by certified acupuncture and homeopathy Specialist.

1.14.e                 Cancer Care and Oncology

Benefits are provided for the prevention and treatment, including any prescribed medications, of tumors, growths, cancer, and malignant neoplasms.

1.14.f                   Kidney Dialysis

Benefits are provided for the transfusion or kidney dialysis of blood, including the cost of: whole blood; blood components; and the administration of whole blood and blood components.

1.14.g                 Home Health Care including Nursing Services

Benefits are provided for Home Nursing and other Home Health Care services. Nursing care is defined as prescribed care that can only be provided by a licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) which is Medically Necessary to treat identified medical conditions on a temporary, limited basis. These services need to meet specified medical criteria to be covered. Home nursing is provided immediately following treatment as an Inpatient on Physician recommendation. Home nursing is not provided solely for the convenience of the family caregiver

Not Covered Under this Benefit

Intermediate, custodial, rest and homelike care services will not be considered skilled and are not covered.

1.14.h                 Hospice Care

Benefits are provided for hospice approved by the Insurer to provide a centrally administered program of palliative and supportive services to a terminally ill Insured Person and their family. Terminally ill refers to the Insured Person having a prognosis of 240 days or less. Covered services are available in home, outpatient and Inpatient settings. The Hospice care guidelines are:

• Must relate to a medical condition that has been the subject of a prior valid claim with the Insurer, with a diagnosis of terminal Illness from a medical doctor,
• Benefit is payable only in relation to care received by a recognized hospice.

1.14.i                   Diabetic Medical Supplies

Benefits are provided for diabetic supplies including test strips, alcohol swabs, lancets, syringes, ketones strips, glucose monitor meter and insulin pumps.

1.14.j                   HIV/AIDS

Benefits are provided for Medically Necessary, non-Experimental services, supplies and medications for the treatment of Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV +), AIDS Related Complex (ARC), sexually transmitted diseases and all related conditions. Refer to the Schedule of Benefits to determine if Pre-Existing Conditions apply to this benefit.

1.14.k                  Durable Medical Equipment

Benefits are provided for items which are designed for and able to withstand repeated use by more than one person and customarily serve a medical purpose. Such equipment includes but is not limited to, wheelchairs, Hospital beds, respirators, and dialysis machines. Such Durable Medical Equipment (DME) must be:

• Prescribed by a Physician,
• Customarily and generally useful to a person only during a covered Illness or Injury,
• Equipment must be appropriate for use in the home and are not disposable, and
• Determined by the Insurer to be Medically Necessary and appropriate.

Allowable rental fee of the Durable Medical Equipment must not exceed the purchase price. Charges for repairs or replacement of artificial devices or other Durable Medical Equipment originally obtained under this Plan will be paid at 50% of the allowable reasonable and customary amount.

Not Covered Under this Benefit

Some items not covered under Durable Medical Equipment include but are not limited to the following:

• Comfort items such as telephone arms and over bed tables, or
• Items used to alter air quality or temperature such as air conditioners, humidifiers, dehumidifiers, and purifiers, or
• Miscellaneous items such as exercise equipment, heat lamps, heating pads, toilet seats, bathtub seats, or
• The customizing of any vehicle, bathroom facility, or residential facility.

High performance devices for sports or improvement of athletic performance, and power enhancement or power- controlled devices, nerve stimulators, and other such enhancements are not covered. Limbs and other devices intended to replace the functionality of the body part being replaced and the repair and replacement of such devices are not covered.

1.14.l                   Alcohol and Substance Abuse Rehabilitative Treatment

Benefits are provided for Inpatient and Outpatient services including diagnosis, detoxification, counseling, and other medical treatment rendered in a Physician's office or by an Outpatient treatment department of a Hospital,

community mental health facility or alcoholism treatment facility, so long as the facility is approved by the Joint Commission on the Accreditation of Hospitals or certified by the Department of Health. The services must be legally performed by or under the clinical supervision of a licensed Physician or a licensed psychologist who certifies that the Insured Person needs to continue such treatment.

1.14.m               Prescription Medications

Benefits are provided for medications which are prescribed by a Physician and which would not be available without such Prescription.

Not Covered Under this Benefit

Certain treatments and medications, such as vitamins, herbs, aspirin, cold remedies, medicines, Experimental and/or Investigational medications, or supplies, even when recommended by a Physician, do not qualify as Prescription Medications. Any medication that is not scientifically or medically recognized for a specific diagnosis or that is considered as off label use, Experimental, or not generally accepted for use will not covered, even if a Physician prescribes it.

1.14.n                 Motor Vehicle Accident

Benefits are provided for injuries sustained in a motor vehicle accident in accordance with the benefits shown in the Schedule of Benefits provided the Insured Person possesses a motor vehicle operator’s license in the jurisdiction in which the motor vehicle Accident occurred.

1.14.o                 Passive War and Terrorism

This Plan covers bodily Injury directly or indirectly caused by, or resulting from certain acts of War and Terrorism, provided the Insured Person is an Innocent Bystander. . This benefit considers the following activities acts of War and Terrorism, excluding the use of nuclear, chemical, or biological weapons of mass destruction.

1. War, hostilities or warlike operations (whether war be declared or not),
2. Invasion,
3. Act of an enemy foreign to the nationality of the Insured Person or the country in, or over, which the act occurs,
4. Civil war, Riot, Rebellion, Overthrow of the legally constituted government,
5. Military or usurped power,
6. Explosions of war weapons,
7. Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the Insured Person whether war be declared with that state or not,
8. Terrorist activity.

2.0   NON-MEDICAL EXPENSE BENEFIT DESCRIPTIONS

ALL NON-MEDICAL EXPENSE BENEFITS MUST BE ARRANGED THROUGH GBG ASSIST. FAILURE TO DO SO WILL RESULT IN NON-PAYMENT OF BENEFITS. PLEASE CONTACT GBG ASSIST IN ADVANCE IN ORDER TO FACILITATE ADMINISTRATION OF THESE BENEFITS.

2.1  Compassionate Care Visit

The Insurer will reimburse travel costs to repatriate the Insured Person to their Home Country in the event there is a serious life-threatening Illness, Injury, or death of a spouse, domestic partner, parent, parent-in-law, child, grandchild, brother, sister or fiancé. The family member must be a resident in the Home Country of the Insured Person. Travel costs include economy round-trip airfare to the Home Country with a return to the Insured Person’s country of study. In all cases, the decision rests solely with the insurance company’s medical representatives who will make the final and binding determination. In the event of death, a certificate of death must be provided.

2.2  Medical Evacuation/Repatriation

In the event of an Emergency that requires medical evacuation or repatriation, contact GBG Assist in advance in order to approve and arrange such emergency medical transportation. GBG Assist, on behalf of the Insurer, retains the right to decide the medical facility to which the Insured Person shall be transported. Approved medical evacuations will only be to the nearest medical facility capable of providing the necessary medical treatment. If the Insured Person chooses not to be treated at the facility and location arranged by GBG Assist, then transportation expenses shall be the responsibility of the Insured Person. Failure to arrange transportation as indicated will result in non-payment of transportation costs. The cost of a person accompanying an Insured Person is covered under this Plan, with expenses subject to pre-approval by GBG Assist.

Sea and Offshore Evacuation: If an Insured Person is Injured or becomes ill at sea (i.e. cruises, yachting, etc.), the Insurer will not consider any benefit until the Insured Person is on land. This means any costs involved from an evacuation from sea to land will not be considered under this Plan. Once on land, this Plan will cover medical costs and further evacuation, according to the insurance coverage and terms. If an Insured Person is at sea, the Insurer would request the Insured Persons are evacuated by sea rescue to a country within their purchased Area of Coverage, where circumstances allow.

Medical Repatriation: If an Insured Person can no longer meet the Eligibility requirements due to medical reasons, GBG Assist and the Insured’s attending Physician will make the determination if Medical Repatriation to the Home Country is necessary. GBG Assist will coordinate return to the Home Country. If the Insured Person refuses Repatriation, the Plan will be terminated for failure to meet Eligibility requirements.

2.3  Return of Mortal Remains

A benefit for either Repatriation of mortal remains, or Local Burial is included. This benefit excludes fees for return of personal effects, religious or secular memorial services, clergymen, flowers, music, announcements, guest expenses and similar personal burial preferences. The necessary clearances for the return of an Insured Person’s mortal remains by air transport to the Home Country will be coordinated by GBG Assist.

3.0   ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT DESCRIPTION

The Insured Person must receive initial medical treatment within 30 days of the date of Accident. The maximum amount payable for this benefit is the Principal Sum indicated on the Schedule of Benefits. If the Insured Person incurs a covered loss, the Insurer will pay the percentage of the Principal Sum shown in the table on the Schedule of Benefits. If the Insured Person sustains more than one such loss as the result of one Accident, the Insurer will only pay one amount, the largest to what the Insured Person is entitled. Except for Accidental Death, the loss must result within the Time Period for Loss of a Covered Accident as shown on the Schedule of Benefits. Your coverage under the Plan must be in force.

Passive War and Terrorism is covered under the AD&D benefit. For purposes of this benefit:

• Loss of a Hand or Foot means complete severance through or above the wrist or ankle joint.
• Loss of Use of a Hand or Foot means total loss of all ability to move the hand or foot, within the Time Period for Loss of a Covered Accident as shown on the Schedule of Benefits, that continues for 6 months and is expected to continue for the remainder of the Insured Person's lifetime.
• Loss of Sight means the total, permanent loss of sight of the eye. The loss of sight must be irrecoverable by natural, surgical or artificial means.
• Severance means the complete separation and dismemberment of the part from the body.

Sanctions Limitation Clause

The Insurer will not provide any cover, pay any claim or provide any benefit under this Plan to the extent that the provision of such cover, the payment of such claim or the provision of such benefit would expose them to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States of America.

1.1  MEDICAL EXPENSE BENEFITS EXCLUSIONS AND LIMITATIONS

All services and benefits described below, including expenses for medical treatment not expressly indicated in the Medical Expense Benefit section, are either excluded from coverage or limited under this Plan of insurance.

1. 1.      Aircraft Travel: Travel in any aircraft owned, leased, operated or controlled by the Policyholder, or any of its subsidiaries or affiliates. An aircraft will be deemed to be “controlled” by the Policyholder if the aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year,
   1. 2.      Alcohol and Substance Abuse:1) Treatment of any Illness or Injury caused by, contributed to, or resulting from voluntary use of alcohol, illegal substance abuse, drug, poison, gas or fumes, or any medication that is not taken in the dosage or for the purpose prescribed. 2) Medical expenses related to diagnosis, detoxification, counseling or other rehabilitative services unless the benefit is provided for on the Schedule of Benefits.
   2. 3.      Breast reduction: All services and treatments,
      1. 4.      Charges Reimbursable by Another Entity: Services, supplies, or treatment that are provided by or payment is available from: a) Workers’ Compensation law, occupational disease law or similar law concerning job related conditions of any country; or; b) Another insurance company or government; or c) A government entity due to an epidemic or public emergency; d) Services provided normally without charge by the Health Services Center of the institution attended by the Insured Person, or services covered or provided by a student health fee,
      2. 5.      Cosmetic and Elective Surgery for Non-Medical Reasons: Treatments, procedures or medications which are primarily for enhancement, improvement, or altering one’s appearance, unless required due to a non- occupational Injury occurring while insured under this Plan. Medical complications arising from such treatments or procedures are also not covered,
      3. 6.      Dental Care: a) All expenses related to dental care except for Accidental injury to sound, natural teeth b) unless pediatric dental is shown on the Schedule of Benefits,
      4. 7.      Experimental or Off-Label Services: Services, supplies or treatments, including  medications, which are

deemed to be Experimental or Investigational or that is not medically recognized for a specific diagnosis,

1. 8.      Fertility/Infertility Treatments and Birth Control: Any services, procedure or treatment including medications used to: a) Treat infertility including In-vitro Fertilization (IVF), Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), and any variations of these procedures, and any costs associated with the preparation or storage of sperm for artificial insemination. b) Vasectomies and sterilization, and any expenses for male or female reversal of sterilization, c) Contraceptive devices including the insertion or removal of such devices, excluding oral contraceptives,
2. 9.      Genetic Screening: Counseling, screening, testing, or treatment in the absence of any symptoms or any

significant, proven risk factors for genetically linked inheritable disease,

1. 10.  Hearing Care: Hearing exams, hearing aids or devices, unless due to an Injury/Illness covered under the Plan. Surgical implantation of, or removal of bone anchored hearing devices and cochlear implants,
2. 11.  Hernia: Treatment of a hernia, including sports hernia whether or not caused by a covered Accident,

1. 12.  Home Country: All medical charges incurred in the Insured Person’s Home Country in excess of the amount shown on the Schedule of Benefits,
2. 13.  Illegal Activities: Injuries or Illnesses resulting or arising from or occurring during the commission of an assault

or felony,

1. 14.  Immunizations for Travel: Vaccines and preventive medications recommended or required for travel to specific countries,
2. 15.  Motor Vehicle: Medical expenses: 1) Resulting from a motor vehicle Accident unless the benefit is provided for on the Schedule of Benefits, 2) If the operator of a motor vehicle is the Insured Person and does not possess a valid motor vehicle operator’s license in the jurisdiction in which the motor vehicle Accident occurred, unless:

(a) the Insured Person holds a valid learners permit and (b) the Insured Person is receiving instruction from a

driver’s education instructor, 3) The operating of any type of vehicle or conveyance while under the influence of alcohol or any illegal substance, drug, poison, gas, or fumes including prescribed drugs for which the Insured was provided a written warning against operating a vehicle or conveyance while taking it. Under the influence of alcohol, for purposes of this exclusion, means intoxicated, as defined by the motor vehicle la ws of the jurisdiction in which the Covered Loss occurred,

1. 16.  Nasal Surgery: Deviated septum, submucous resection and/or other surgical correction thereof, nasal and sinus surgery except for treatment of a covered Injury,
2. 17.  Non-Medical Care: Services related to Custodial Care, respite care, home-like care, assistance with Activities of

Daily Living (ADL), or Milieu Therapy. Any Admission to a nursing home, home for the aged, long term care facility, sanitarium, spa, hydro clinic, or similar facilities. Any Admission arranged wholly or partly for domestic reasons, where the Hospital effectively becomes or could be treated as the Insured Person’s home or permanent abode,

1. 18.  Organ Transplant: Organ transplant and related procedures and expenses,
   1. 19.  Podiatric Care: Routine foot care, including the paring and removing of corns, calluses, or other lesions, or trimming of nails or other such services not resulting from an Illness or Injury. Orthopedic shoes or other supportive devices such as arch supports, orthotic devices, or any other preventative services or supplies to treat the diagnosis of weak, strained, or flat feet or fallen arches.
   2. 20.  Prescription Medications: Prescription Medications, services or supplies as follows:

a)       Therapeutic devices or appliances including: support garments and other non-medical substances, regardless of intended use, except as specifically provided in this Plan, b) Immunization agents, except as specially provided, biological sera, blood or blood products administered on an Outpatient basis, c) Refills in excess of the number specified or dispensed after one year of the date of the prescription, d) Growth hormones, e) Medications used to treat or cure baldness or thinning hair.

21.  Self-Inflicted Illnesses, Injuries, or Exceptional Danger:

1. Treatment for any conditions as a result of self-inflicted Illnesses or injuries, suicide or attempted suicide, while sane or insane,
2. Treatment for any loss or expense of nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with self-exposure to peril or bodily Injury, except in an endeavor to save human life,
3. 22.  Sexual  Dysfunction:  Any  procedures, supplies, or medications  used to treat male  or female  sexual enhancement or sexual dysfunction such as erectile dysfunction, premature ejaculation, and other similar conditions,

1. 23.  Skin Conditions: Acne, rosacea, skin tags, and any other treatment to enhance the appearance of the skin, except for cystic or pustular acne,
2. 24.  Sleep Studies: Sleep studies and other treatments relating to sleep apnea,
3. 25.  Smoking Cessation: Treatments and other expenses, whether or not recommended by a Physician,
   1. 26.  Sports and Hazardous Activities: a) Participation, practice, or conditioning program for any, Intercollegiate, or professional sport or competition, including cheerleading or travelling to/from such sport or competition as a participant, b) Skydiving, parachuting, SCUBA diving (unless PADI or NAUI certified), mountain climbing (where ropes or guides are used), bungee jumping, skiing (off groomed trails), snowboarding (off groomed trails), racing by any animal or motor vehicle, spelunking, whitewater rafting (level 4 and higher), hang gliding, glider flying, parasailing, or flight in any kind of aircraft (except as a passenger in a regularly scheduled flight of a commercial airline), c) Power Vehicles: Expenses for Accidents or Injuries as a result of motorcycles, mopeds, scooters, ATV’s, any one, two, or three wheeled motorized vehicle and/or sport watercraft such as wave runners, jet skis, or other powered devices whether the vehicle is in motion or not,

1. 27.  Transsexual Surgery: Medical or psychological counseling, hormonal therapy in preparation for, or subsequent to, any such surgery, surgical procedures, and any other expenses related to sexual reassignment including the complications arising from such procedures,
2. 28.  Vision Care: Expenses including examinations, eye refractions, frames, lenses, contact lenses, fitting of frames

or lenses, or vision correction surgery, unless the pediatric vision benefit is shown on the Schedule of Benefits,

1. 29.  War and Terrorism: a) Any loss sustained while participating in, or training for, or as a consequence of war (declared or not), or warlike operations, b) voluntary, active participation in a riot or insurrection, c) Terrorist activity including the use of armaments, the detonation of any form of explosive or nuclear devices, the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous Chemical agent and/or Biological agent, including the poisoning via the air or water supplies or food products and deliberate destruction of buildings and transportation. This exclusion extends to any action taken in controlling, preventing, suppressing or in any way relating to any terrorist activity, d) Ionizing radiations or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel, or the radioactive, toxic, explosive or other hazardous properties of any explosive nuclear assembly or nuclear component thereof,
2. 30.  Weight Related Treatment: Any expense, service, or treatment for obesity, weight control, any form of food supplement, weight reduction programs, dietary counseling, or surgical procedures related to morbid or non- morbid obesity. Charges relating to complications arising from such treatments or surgical procedures are also excluded,
3. 31.  Services or treatment rendered by any person who is: a) living in the Insured Person’s household, b) an Immediate Family Member of either the Insured Person or the Insured Person’s spouse, or c) the Insured Person.

1.2  NON-MEDICAL EXPENSE BENEFITS EXCLUSIONS AND LIMITATIONS

The Insurer shall not be responsible for providing the following non-medical expense benefits to an Insured Person in a situation arising from or in connection with any of the following:

1. Travel costs that were neither arranged or approved in advance by the Insurer or authorized vendor or affiliate,
2. Taking part in military or police operations,
3. Insured Person’s failure to properly procure or maintain visa, permits, or other documents,
   1. The actual or threatened use or release of any nuclear, chemical, or biological weapon or device, or exposure to nuclear reaction or radiation, regardless of the contributory cause,
   2. Any evacuation or Repatriation that requires an Insured Person to be transported in a biohazard-isolation unit,
   3. Medical evacuation from a marine vessel, ship, or watercraft of any kind,
   4. Medical evacuation directly or indirectly related to a natural disaster,
      1. Subsequent medical evacuations for the same or related Illness, Injury, or emergency medical evacuation event regardless of location.

1.3  ACCIDENTAL DEATH AND DISMEMBERMENT EXCLUSIONS AND LIMITATIONS

The losses shown below or expenses resulting from or in connection with any of the following are excluded from coverage under this Plan.

1. Illegal Activities: Losses resulting or arising from or occurring during the commission of an assault or felony.
   1. Kidnap and Hijacking: Any loss caused directly or indirectly from kidnap or wrongful detention of the Insured or hijacking of any aircraft, motor vehicle, train or waterborne vessel on which the Insured Person is travelling.

PRE-AUTHORIZATION REQUIREMENTS AND PROCEDURES

Pre-Authorization is a process by which an Insured Person obtains approval for certain medical procedures or treatments prior to the commencement of the proposed medical treatment. This requires the submission of a completed Pre-Authorization Request form to GBG Assist a minimum of five business days prior to the scheduled procedure or treatment date.

The following services require Pre-Authorization:

• Any Hospitalization,
• Outpatient or Ambulatory Surgery,
• All Cancer Treatment (Including Chemotherapy and Radiation),
• Prescription medications in excess of $3,000 per refill,
• Medical Evacuation/Repatriation and all other Non-Medical Expense benefits,
• Any condition, which does not meet the above criteria, but are expected to accumulate over $10,000 of medical treatment per Period of Insurance.

Either you, your doctor, or your representative must call the number listed on the back of the Medical Identification Card to obtain Pre-Authorization and verification of Network utilization. Prior to the performance of services, a letter of authorization will be provided.

Medical Emergency Pre-Authorizations must be received no later than 48 hours after the Admission or procedure. In instances of an emergency, you should go to the nearest Hospital or Provider for assistance even if that Hospital or Provider is not part of the Network.

Failure to obtain pre-authorization will result in a 30% reduction in payment of covered expenses. Any such penalty will apply to the entire episode of care and does not apply to the Out-of-Pocket maximum. If treatment would not have been approved by the pre-authorization process, all related claims will be denied.

Pre-Authorization approval does not guarantee payment of a claim in full, as additional Copayments and Out-of- Pocket expenses may apply. Benefits payable under the Plan are still subject to Eligibility at the time charges are actually incurred, and to all other terms, limitations, and exclusions of the Plan.

In the event of an emergency that requires medical evacuation, contact GBG Assist in advance in order to approve and arrange such emergency medical transportation. GBG Assist, on behalf of the Insurer, retains the right to decide the medical facility to which the Insured Person shall be transported. Approved medical evacuations will only be to the nearest medical facility capable of providing the necessary medical treatment. If the person chooses not to be treated at the facility and location arranged by GBG Assist, then transportation expenses shall be the responsibility of the Insured Person. Failure to arrange transportation as indicated will result in non-payment of transportation costs.

1.0   HOW TO FILE A CLAIM

Claims must be filed within 180 days of treatment to be eligible for reimbursement of covered expenses. Claim forms should be submitted only when the medical service Provider does not bill the Insurer directly, and when you have out-of-pocket expenses to submit for reimbursement. All claims worldwide are subject to Usual, Customary, and Reasonable charges as determined by GBG and are processed in the order in which they are received. In order for claims payment to be made, claims must be submitted in a form acceptable to Insurer.

1.1  Medical Claims

To file your claim, submit it online at www.gbg.com. Log into the Member Area and select Submit Claim, and then follow the instructions to complete the online claim form. If you are unable to submit your claim electronically, you can mail or fax your completed claim form and copies of supporting documentation. After submitting the claim, you will receive a claim reference number and an electronic receipt for the claim will be sent to you by email.

Claims may be submitted to the Insurer directly by the Provider or Facility. The Insurer will process the claim according to the Schedule of Benefits and Plan terms, and remit payment to the health care Provider. Ineligible charges or those in excess of the Allowable Charges will be the responsibility of the Insured Person.

If the Insured Person has paid the health care Provider, the Insured Person will submit the claim form along with the original paid receipts directly to the Insurer. Photocopies will not be accepted unless the Claim is submitted electronically. The Insurer will reimburse the Insured Person directly according to the Schedule of Benefits and Plan terms.

1.2  Accidental Death and Dismemberment Claims

To substantiate a claim for benefits covered by the terms of this Plan, the following initial documents must be submitted:

• An official certificate of death, indicating date of birth of the Insured Person;
  • A detailed medical report at the onset and course of the disease, bodily Injury or Accident that resulted in the death or dismemberment. In the event of no medical treatment, a medical or official certificate stating the cause and circumstances of death;
  • The Insurer will pay the benefit as soon as the validity of the claim for benefits has been reasonably satisfied. Expenses incurred in relation to the substantiation of a claim will not be the responsibility of the Insurer.

1.3  Submit Claims By:

 1.4  Reimbursement Options

Claims reimbursements will be made by:

• Electronic Direct Deposit for the Insured Person where the receiving bank is located in the U.S.,
• Wire Transfer for the Insured Person’s and overseas Providers where the receiving bank is located outside

of the U.S., or

• Check sent to the Insured Person or Provider where electronic payment is not possible.

 1.5  Settlement of Claims

When claims are presented to the Insurer, the Allowable Charges will be applied towards the Deductible. Once the Deductible has been satisfied, all Allowable Charges will be paid at the percentage listed on the Schedule of Benefits, up to the listed benefit maximum. Note the amount of Allowable Charges applied towards the Deductible also reduces the applicable benefit maximum by the same amount.

If the Plan has an Out-of-Pocket Maximum, once it is met the Plan will begin paying 100% of Allowable Charges for the remainder of insurance coverage, subject to the benefit maximums. The Out-of-Pocket Maximum does not apply to any expenses covered under the Prescription Medications benefit.

1.6  Status of Claims

Insured Person’s wishing to request the status of a claim or have a question about a reimbursement received, please submit the status request form via our website at www.gbg.com or e-mail customer service at customerservice@gbg.com. Inquiries regarding the status of past claims must be received within 12 months of the date of service to be considered for review.

1.7  Releasing Necessary Information

It may be necessary for the Insurer to request a complete medical file on an Insured Person for purpose of claims review or administration of the Plan. It may also be necessary to share such information with a medical or utilization review board, or a reinsurer. The release of such confidential medial information will only be with written consent of the Insured Person.

1.8  Coordination of Benefits

The Coordination of Benefits (COB) provision applies when an Insured has health care coverage under more than one health insurance policy or health insurance plan (a “Plan”). This includes group and non-group insurance contracts, health maintenance organization (HMO) contracts, medical benefits under group or individual automobile contracts, and Medicare or any other federal governmental plan.

The order of benefit determination rules governs the order in which each Plan will pay a claim for benefits. The Plan that pays first is called the Primary Plan. The Primary Plan pays benefits in accordance with its policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans does not exceed 100% of the total Allowable Expense.

Order of Benefit Determination Rules

When an Insured is covered by two or more health care plans or policies, the rules for determining the order of benefits follows:

• If a Plan does not have a Coordination of Benefits provision, it will always be the Primary Plan.
  • The Plan that covers the claimant as the Primary Insured, (in the case of this Policy, a Class 1 Eligible Person shown on the Schedule of Benefits) is the Primary Plan and the Plan that covers this person as a dependent is the Secondary Plan.
  • The Plan that covers the claimant as a Dependent Spouse or Child (in the case of this Policy other than as a Class 1 Eligible Person shown on the Schedule of Benefits) is the Secondary Plan and the Plan that covers this person other than as a Dependent is the Primary Plan.
    • If two Plans cover the claimant as a Primary Insured, the Plan that has covered this person for the longer period of time is the Primary Plan.
    • If two Plans cover the claimant as a Dependent Child, the Plan of the parent whose birthday falls earlier in the calendar year is the Primary Plan. If both parents have the same birthday, the Plan that has covered the parent the longest is the Primary Plan.

If an educational institution, Participating Organization, or any other entity provides health coverage for organized sports and activities, such coverage is the Primary Plan and this coverage will be a Secondary Plan.

1.9  Subrogation, Reimbursement and Assignment of Rights

Benefits paid under the Plan are paid on the condition that We are entitled to pursue subrogation and receive reimbursement for an Injury or Illness for which We have provided benefits when You have accrued a right of action against a third party for causing an Injury or Illness for which i) We have paid benefits; and ii) You have received a judgment, settlement, or other compensation on the basis of that Illness or Injury or are entitled to receive compensation or recovery on the basis of that Illness or Injury. We have the right to be reimbursed whether the recovery You receive, or to which You are entitled, is made in a single payment or incrementally over time. Our reimbursement and subrogation rights extend to all amounts available to You or that You have received by judgment, settlement or other recovery, including but not limited to benefits from policies of insurance issued to You and/or in the name of a covered family member or that otherwise inure to Your benefit. We automatically have a lien on any payment You receive or are entitled to receive from any person or entity because of a claim for which We have paid benefits. The lien may be enforced against any party who acquires funds arising out of or attributable to the claim.

Our obligation to pay benefits is always secondary to any automobile No-Fault /Personal Injury Protection or medical payments coverage. To the extent that We have paid a benefit for an amount that is payable by any automobile No-Fault /Personal Injury Protection or medical payments coverage, We shall have the right to collect any such amount from the automobile insurer.

You and any of Your legal representatives shall fully cooperate with Our efforts to recover the benefits We have paid. You must notify Us within 30 days of the date when notice is given to any party, including an insurance company or attorney, of Your intention to pursue or investigate a claim to recover damages or obtain compensation due to the Injury, Illness or condition for which We have paid benefits. You shall do nothing to prejudice Our subrogation or recovery interests or Our ability to enforce the terms of these provisions. We have the sole authority and discretion to decide whether to pursue any right of recovery under this provision.

We are entitled to and may pursue any and all parties who may be liable to provide compensation to You for the claim at Our expense and may bring such action in Our name as Your subrogee/assignee. You agree to fully assist Us in pursuit of Our rights of subrogation if We do so by assignment.

10.0   APPEALS PROCEDURE

If a claim is wholly or partially denied, a written notice will be sent to the Insured Person containing the reason for the denial. The notice will include a reference to the provision in the Plan description and a description of any additional information which might be necessary for reconsideration of the claim. The notice will also describe the right to appeal. A written appeal, along with any additional information or comments, may be sent within 6 months after notice of denial. In preparing the appeal, the Insured Person, or their representative, may review all documents related to the claim and submit written comments and issues related to the denial. After the written notice is filed and all relevant information is presented, the claim will be reviewed, and a final decision sent within 60 days after receipt of the notice of the appeal. Under special circumstances, an extension for further review will be granted, but not for longer than 60 additional days.

11.0   COMPLAINTS PROCEDURE

GBG is committed to providing Insured’s with an exceptional level of service and customer care. Sometimes things can go wrong or there may be occasions when the service provided to you was not ad equate. When this happens, please contact GBG and give us the opportunity to correct the situation and earn back your trust.

Who to Contact?

The most important factors in getting Your complaint dealt with as quickly and efficiently as possible are:

• Be sure You are talking to the right person; and
• That You are providing the necessary information.

When You Contact Us

Please provide the following information:

• Your name, telephone number, and email address;
• Your Plan and/or claim number and the plan of benefits (medical, travel, disability) You are insured for; and
• Please explain clearly and concisely the reason for Your complaint.

Making a Complaint

If Your complaint relates to:

1.      The sale of the Plan You purchased or any information You were given during the sales process:

1. If You purchased the Plan using a broker or other intermediary, please contact them first.
2. If You purchased the Plan directly from Us either from a local representative, using the website, or through a group plan of benefits, please contact Us directly at:

 You may also submit Your complaint via Our Complaint Form, which may be accessed by visiting Our website and navigating to the Forms page: www.gbg.com/#/oursolutions/forms.

 2.      A claim for benefits, the terms and conditions of the Plan, or other benefit related information:

1. Complaints related to a claim denial should be submitted as soon as possible. We will review the information and provide a response within four weeks or will request additional time, if needed.
2. Claims and benefits related complaints should be referred to Our Complaints Department:

 You may also submit Your complaint via Our Appeal Form, which may be accessed by visiting Our website and navigating to the Forms page: www.gbg.com/#/oursolutions/forms.

We always aim to resolve Your complaint and provide a final response within four weeks, but if it looks like it will take Us longer than this, We will let You know the reasons for the delay and inform You of the options available to You.

12.0   LAW AND JURISDICTION

This insurance is governed by the laws of the Cayman Islands. Any laws governing the terms, conditions, benefits and limitations in health insurance policies issued and delivered in other countries are not applicable.

13.0   PRIVACY NOTICE

Crum & Forster SPC (“The Company”) values Your business and Your trust. In order to administer insurance policies and provide You with effective customer service, We must collect certain information including nonpublic personal information about our customers and claimants. Nonpublic personal information means infor mation that allows someone to identify or contact You (“Information”). We are committed to protecting such Information and We will comply with all applicable federal and state laws and regulations. This notice describes how We collect, use and share Your Information, Your rights with respect to insurance products issued by The Company and Our legal duties and privacy practices. State laws require that We provide this notice. Please review this notice and keep a copy of it with Your records.

Your privacy is Our concern

When You apply to The Company for insurance or make a claim against a policy written by The Company, You disclose information about yourself to Us. The Company limits the collection, use, and disclosure of such information to only what is needed to properly produce, underwrite and service its insurance products and/or fulfill legal or regulatory requirements. The Company maintains administrative, technical and physical safeguards that comply with state and federal regulations to protect Your Information. We also limit employee access to information to those with a business reason for knowing such Information and We take measures to enforce employee privacy responsibilities.

What kind of information do We collect about You and from whom?

We obtain most of our Information from You. The application or claim form You complete, as well as any additional information You provide, generally gives Us most of the information We need to know. Sometimes We may contact You by phone or mail to obtain additional information. We may use information about You from other transactions with Us, Our affiliates, or others. Depending on the nature of Your insurance transaction, We may need additional information about You or other individuals proposed for coverage. We may obtain the additional information We need from third parties, such as other insurance companies or agents, government agencies, medical providers, insurance support organizations, the state motor vehicle department, information clearinghouses, credit reporting agencies, courts, or public records. A report from a consumer reporting agency may contain information as to creditworthiness, credit standing, credit capacity, character, general reputation, hobbies, occupation, personal characteristics, or mode of living.

What do We do with the information collected about You?

The Company collects nonpublic information to conduct its business of producing, underwriting, servicing and administering its insurance products. If coverage is declined or the charge for coverage is increased because of information contained in a consumer report We obtained, We will inform You, as required by state law or the federal Fair Credit Reporting Act. We will also give You the name and address of the consumer reporting agency making the report. We may retain information about Our former customers and may disclose that information to affiliates and non-affiliates only as described in this notice.

To whom do We disclose information about You?

Access to non-public personal information is limited to those employees, and authorized representatives, attorneys and service providers who specifically need such information to conduct their business responsibilities. In addition, We may disclose all the information that We collect about You to affiliated companies and nonaffiliated third parties (as permitted by law), such as:

• Insurance companies;
• Insurance agencies;
• Loss adjusters;
• Medical providers;
• Third party non-insurance service providers;
• Third party administrators;
• Medical bill review companies;
• Reinsurance companies; and
• Similar service providers.

Crum & Forster requires its service providers to abide by privacy laws in handling non-public personal information obtained through its business relationship with Crum & Forster. Additionally, Crum & Forster may disclose non- public personal information to third parties as allowed or required by law. For example, Crum & Forster may release your Information to comply with reporting requirements, to comply with a subpoena, warrant, legal process or other order or inquiry of a court, governmental agency or state or federal regulator, or to fulfill C&F’s obligations to its insurers and reinsurers  We may also share Your personal information in order to establish or exercise our rights, to defend against a legal claim, to investigate, prevent, or take action regarding possible illegal activities, suspected fraud, safety of person or property, or a violation of Our policies.