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 If any information is incorrect or incomplete, or if any information has been omitted, the insurance coverage may be rescinded or terminated.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 whowill 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.

The following Medical Expense Benefits are subject to the Insured Person’s Deductible, Copayment, and Coinsurance amount. After satisfaction of the Deductible and applicable Copayments, the Insurer will pay eligible benefits set forth in this Schedule at the specified Plan Coinsurance and reimbursement level.

GENERAL FEATURES AND PLAN SPECIFICATIONS

U.S. Provider Network

United Healthcare

Area of Coverage

United States, Excluding Home Country

Maximum Benefit Payable per Period of Insurance

$300,000 to an overall $500,000 maximum for all covered Illness or Injury combined

Lifetime Maximum

Unlimited

Individual Deductible per Period of Insurance

 

  • In-Network Provider

$1500 per Insured Person

2x Individual per family

  • Out-of-Network Provider

$500 per Insured Person

2x Individual per family

The Deductible for In-Network does not accrue towards the Out-of-Network Deductible.

Copayments

Copayments do not apply to the Deductible or the Out-of-Pocket Maximum.

  • Student Health Center Copayment

$25 per visit not subject to Deductible

  • Physician/Specialist Office Visit Copayment

$40 per visit

  • Urgent Care Center Copayment

$50 per visit

  • Hospital Copayment per Admission

$350

  • Emergency Room Visit Copayment

(Waived if admitted)

$300 per visit

Out-of-Pocket-Maximum per Period of Insurance

 

  • In-Network

Unlimited per Insured Person

  • Out-of-Network

Unlimited per Insured Person

The Deductible does not apply to the Out-of-Pocket Maximum (refer to the definition of Out-of-Pocket Maximum for applicability).

Pre-Existing Condition Limitation

(12 months Lookback Period)

Student and Dependents: Pre-Existing Conditions are covered after a 6 months Waiting Period

NOTE: Deductible and Copayment will be waived when treatment is rendered at the Student Health Center. Benefits will be paid at the In-Network Coinsurance percentage, subject to Usual, Customary and Reasonable charges.

 

COVERED SERVICES AND BENEFIT LEVELS

Subject to Deductible, Coinsurance, Copayment, and Maximum Benefit per Period of Insurance

WHAT THE INSURANCE PLAN COVERS

The following Coinsurance applies for In-Network Providers in the U.S. or for expenses incurred outside the U.S. (if available). Coinsurance reduces to 70% UCR when Out-of-Network Providers in the

U.S. are used.

HOSPITALIZATION AND INPATIENT BENEFITS

Accommodations including semi-private room

80% Preferred Allowance

Intensive Care/Cardiac Care

80% Preferred Allowance

Mental Health

80% Preferred Allowance

Inpatient Consultation/Visit by a Physician or Specialist

80% Preferred Allowance

Diagnostic Testing and Hospital Miscellaneous Expense

80% Preferred Allowance

Pre-Admission Testing

80% Preferred Allowance


OUTPATIENT BENEFITS

Physician Visit or Consultation by Specialist

  • Office visit Copayment applies
  • Urgent Care Center Copayment applies

 

80% Preferred Allowance

Diagnostic Testing

  • X-Ray and Laboratory
  • MRI, PET, and CT scans
  • Office visit Copayment applies when testing is done

outside an office visit.

 

 

80% Preferred Allowance

Therapeutic Services, Physical Therapy, Chiropractic, Occupational Therapy, Vocational, and Speech Therapy

  • Maximum Benefit per Injury or Illness: 12 visits
  • Office visit Copayment applies

 

 

80% Preferred Allowance

Mental Health

  • Office visit Copayment applies

80% Preferred Allowance

SURGICAL BENEFITS (INPATIENT/OUTPATIENT)

Inpatient, Outpatient or Ambulatory Surgery Includes:

  • Surgeon’s Fees
  • Out of network Assistant Surgeon or Anesthesiologist (up to 25% of Usual, Customary & Reasonable for surgery)
  • Facility fees
  • Laboratory tests
  • Medications and dressings
  • Other medical services and supplies

 

 

 

80% Preferred Allowance

EMERGENCY BENEFITS

Emergency Room and Medical Services

  • Copayment waived, if admitted
  • 70% Coinsurance for non-emergency use

 

80% Preferred Allowance

Ambulance Services

  • Emergency local ground ambulance

80% Preferred Allowance

Emergency Dental

  • Limited to accidental Injury of sound natural teeth sustained while covered
  • Maximum Benefit per Period of Insurance: $1,000 up to $250 per tooth

 

80% Preferred Allowance

The following Waiting Period(s) applies to Maternity Care benefits: • Primary Insured: Conception must occur while covered under the Plan. • Dependent Spouse: Conception must occur while covered under the Plan

 

Normal delivery or Medically Necessary Caesarean Section, pre-natal care, and post-natal care

80% Preferred Allowance

Complications of Pregnancy, premature birth, and birth anomalies

80% Preferred Allowance

 

OTHER BENEFITS (INPATIENT/OUTPATIENT)

Elective Abortion

  • Maximum Benefit per Period of Insurance: $500

80% Preferred Allowance

Homeopathic Care and Acupuncture

  • Office visit Copayment applies

 

80% Preferred Allowance

Cancer Care and Oncology

80% Preferred Allowance

Kidney Dialysis

80% Preferred Allowance

Durable Medical Equipment

  • Reimbursement of rental up to the purchase price

80% UCR

Alcohol and Substance Abuse

  • Office visit Copayment applies

80% Preferred Allowance

 

OTHER BENEFITS (INPATIENT/OUTPATIENT) (CONTINUED)

Prescription Medications

  • Up to 31-day supply per prescription
  • Includes oral contraceptives
  • CVS/Caremark network pharmacy is required

80% of charges

Sports and Other Activities

  • Injuries arising from Interscholastic, Intramural, and Club sports
  • Maximum Benefit per Period of Insurance: $5,000

 

80% Preferred Allowance

Passive War and Terrorism

Included

 NON-MEDICAL EXPENSE BENEFITS

Non-Medical Expense Benefits do not accumulate towards the Medical Expense Maximum Benefit payable per Period of Insurance or toward the Lifetime Maximum.

 

ADDITIONAL BENEFITS

Compassionate Care Visit

  • Maximum Benefit per Period of Insurance: $10,000

Included

Medical Evacuation and Repatriation

Maximum Benefit per Period of Insurance: $120,000

Included

Return of Mortal Remains

Maximum Benefit: $60,000

Included

 

ACCIDENTAL DEATH AND DISMEMBERMENT

Principal Sum for Primary Insured Person

$10,000

Time Period for Loss

90 days from the date of the covered Accident

Loss of:

Benefit: Percentage of Principal Sum

Accidental Death

100%

Loss of Both Hands or Feet, or Loss of Entire Sight of Both Eyes

100%

Loss of One Hand and One Foot

100%

Loss of One Hand or Foot and Entire Sight of One Eye

100%

Loss of One Hand or Foot

50%

Loss of Sight of One Eye

50%

DEFINITIONS

Certain words and phrases used in this Plan are defined below. Other words and phrases may be defined where they are use

Accident: Any sudden and unforeseen event occurring during the insurance coverage year period, resulting in bodily Injury, the cause or one of the causes of which is external to the Insured Person’s own body and occurs beyond the Insured Person’s control.

Activities of Daily Living (ADL): Activities of daily living are those activities normally associated with the day-to- day fundamentals of personal self-care, including but not limited to: walking, personal hygiene, sleeping, toilet/continence, dressing, cooking/feeding, medication, and getting in and out of bed.

Acute Care: Medically Necessary, short-term care for an Illness or Injury, characterized by rapid onset, severe symptoms, and brief duration, including any intense symptoms, such as severe pain.

Admission: The period from the time that an Insured Person enters a Hospital, Extended Care Facility or other approved health care facility as an Inpatient until discharge.

Allowable Charge: The fee or price the Insurer determines to be the Usual, Customary and Reasonable Charges for health care services provided to Insured Persons. The Insured Person is responsible for the payment of any balance over the Allowable Charge (except in the U.S. when a Preferred Provider has delivered the service). All services must be Medically Necessary. Once an Allowable Charge is established, then the Deductible, Coinsurance, Copayments and any excess charges must be paid by the Insured Person.

Ambulatory Surgical Center: A facility which (a) has as its primary purpose to provide elective surgical care; and

(b) admits and discharges a patient within the same working day; and (c) is not part of a Hospital. Ambulatory Surgical Center does not include: (1) any facility whose primary purpose is the termination of pregnancy; (2) an office maintained by a Physician for the practice of medicine; or (3) an office maintained by a Dentist for the practice of Dentistry.

Benefit Period: A period, shown in the Schedule of Benefits and commencing with the date of the first expense incurred for treatment of an Injury sustained in an Accident or the date of the first treatment of illness, during which benefits are payable.

Club Sports: Any sports offered at a university or college in the United States that compete with other universities, or colleges, but are not regulated by the National Collegiate Athletic Association (NCAA) or National Association of Intercollegiate Athletics (NAIA), and do not have varsity status.

Coinsurance: The percentage amount of the Allowable Charges that the Insured Person and the Insurer will share after the Deductible and Copayment is met.

Common Carrier: An individual, a company, or public utility which is in the regular business of transporting people and for which a fare has been paid.

Complications of Pregnancy: A condition

  • Caused by pregnancy; and
  • Requiring medical treatment prior to, or subsequent to termination of pregnancy; and
  • The diagnosis of which is distinct for pregnancy; and
  • Which constitutes a classifiably distinct complication of pregnancy.

A condition simply associated with the management of a difficult pregnancy is not considered a complication of pregnancy.

Confinement: Inpatient stay at an approved extended care facility for necessary skilled treatment or Rehabilitation in accordance with the contract.

Congenital Condition: Any heredity condition, birth defect, physical anomaly and/or any other deviation from normal development present at birth, which may or may not be apparent at that time. These deviations, either physical or mental, include but are not limited to, genetic and non-genetic factors or inborn errors of metabolism.

Copayment: A fixed dollar amount that may be applied per office visit each time medical services are received. Ancillary services such as Laboratory and Radiology service (i.e. blood tests, x-rays) that may be in conjunction with an office visit do not require a separate Copayment. Copayments do not apply to the Deductible, Coinsurance or to the Out-Of-Pocket Maximum.

Cosmetic Surgery: Surgery or therapy performed to improve or alter appearance for self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance.

Covered Expense: Charges that are Medically Necessary and that are:

  1. Not in excess of the maximum amount payable for services as specified in the Schedule of Benefits;
  2. In excess of any Deductible amount; and
  3. Incurred while the Insured Person’s coverage under this Plan is in force.

Custodial Care: Includes: (1) the provision of room and board, nursing care, or such other care which is provided to an individual who is mentally or physically disabled and who, as determined by the individual’s attending Physician, has reached the maximum level of recovery; and (2) in the case of an institutionalized person, room and board, nursing care or such other care which is provided to an individual for whom it cannot reasonably be expected that medical or surgical treatment will enable him to live outside an institution; and (3) rest cures, respite care and home care provided by family Insureds. Upon receipt and review of a claim, the Insurer or an independent medical review will determine if a service or treatment is Custodial Care.

Deductible: The amount of covered Allowable Charges payable by the Insured Person during each Period of Insurance before the Plan benefits are applied. Such amount will not be reimbursed under the Plan. The Deductible is not considered part of the Out-Of-Pocket Maximum.

Dentist: A person who is: 1) Licensed to practice dentistry in the state where the dental procedure is performed; and 2) Operating within the scope of his or her license; or 3) Licensed or certified to perform dental procedures in the state where the dental procedure is performed.

Dependent: Refers to a member of the Insured Person’s family who is enrolled under the Plan with the Insurer after

meeting all the Eligibility requirements and for whom Premiums have been received.

Dependent Child: The Insured Person’s unmarried child who meets the following requirements: a child from birth to 19 years old;

A dependent child, for purposes of this definition, includes the Insured Person’s:

  1. natural child;
  2. adopted child;
  3. stepchild who resides with the Insured Person.

Durable Medical Equipment: Motorized wheelchairs, beds, orthopedic braces, artificial devices replacing body parts and other equipment customarily and generally useful to a person only during an Illness or Injury and determined by Insurer to be Medically Necessary.

Effective Date: The date upon which the Insured Person’s coverage will commence under this Plan.

Eligible Person: An individual as defined in the Schedule of Benefits.

Eligibility: The requirements that all Insured Persons including Eligible Dependents, must meet at all times in order to be covered under this Plan.

Emergency Dental Treatment: Emergency Dental treatment is urgent treatment necessary to restore or replace sound natural teeth damaged as a result of an Accident. Sound teeth do not include teeth with previo us crowns, fillings, or cracks. Damage to teeth caused by chewing foods does not qualify for Emergency Dental coverage.

Experimental and/or Investigational: Any treatment, procedure, technology, facility, equipment, medication, medication usage, device, or supplies not recognized as accepted medical practice by Insurer.

Extended Care Facility: A nursing and/or Rehabilitation center approved by Insurer that provides skilled and Rehabilitation services to patients who are discharged from a Hospital or who are admitted in lieu of a Hospital stay. The term Extended Care Facility does not include nursing homes, rest homes, health resorts, homes for the aged, infirmaries or establishments for domiciliary care, Custodial Care, care of substance abuse addicts or alcoholics, or similar institutions.

HIV: Acquired Immune Deficiency Syndrome (AIDS) and all diseases caused by and/or related to the HIV Virus.

Home Country: The country from which the Insured Person holds a passport. If the Insured Person holds passports from more than one country, the Home Country will be the country declared to in writing as their Home Country.

Home Health Agency: an entity engaged in arranging and providing nursing services, home health services or other therapeutic and related services. The entity must be certified by a competent governmental authority in the jurisdiction where the services are rendered and meeting the requirements of Title XVIII of the Social Security Act, as amended, for home health agencies.

Home Health Care Plan: A program: 1) for the care and treatment of an Insured Person in his home; 2) established and approved in writing by his attending Physician; and 3) Certified, by the attending Physician, as required for the proper treatment of the Injury or Illness, in place of Inpatient treatment in a Hospital or in an Extended care Facility.

Hospice: An agency which provides a coordinated Plan of home and Inpatient care to a terminally ill person and which meets all of the following tests: 1) has obtained any required state or governmental license or Certificate of Need; 2) provides service 24-hours-a-day, 7 days a week; 3) is under the direct supervision of a Physician; 4) has a Nurse coordinator who is a Registered Nurse (R.N.) or a Licensed Practical Nurse (L.P.N.); 5) has a duly licensed social service coordinator; 6) has as its primary purpose the provision of Hospice services; 7) has a full-time administrator; and 8) maintains written records of services provided to the patient.

Hospital: Includes only Acute Care facilities licensed or approved by the appropriate regulatory agency as a Hospital, and whose services are under the supervision of, or rendered by a staff of Physicians who are duly licensed to practice medicine, and which continuously provides twenty-four (24) hour a day nursing service under the direction or supervision of registered professional Nurses. The term Hospital does not include nursing homes, rest homes, health resorts, and homes for the aged, infirmaries or establishments for domiciliary care, Custodial Care, care of substance abuse addicts or alcoholics, or similar institutions.

Illness: Any disease, sickness or infection, other than those related to psychiatric illness or mental stress, contracted

after the Effective Date of an Insured Person’s coverage.

Immediate Family Member: A person who is related to the Insured Person in any of the following ways: Spouse, brother-in-law, sister-in-law, daughter-in-law, son-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister), or child or granchild (includes legally adopted or stepchild/grandchild).

Injury: means bodily harm caused by an Accident. The Accident must occur while the Insured Person’s insurance is in force under this Plan. All Injuries sustained by one person in any one accident, including all related conditions and recurrent symptoms of these Injuries, are considered a single covered Injury. The Injury must be the direct cause of an Accident covered under this Plan and must be independent of all other causes. The Injury must not be caused by or contributed to by Illness.

Innocent Bystander: An individual who is judged to be not involved with, participating in, or related to their work, any activity associated with any war, conflict or terror related activity. This includes any hostilities or warlike operations (whether war be declared or not), invasion, civil war, riot, rebellion, overthrow of the legally constituted government, military or usurped power and any terrorist activity.

Inpatient: An Insured Person admitted to an approved Hospital or other health care facility for a Medically Necessary overnight stay.

Insured Person or Insured: Any person who is listed as an Eligible Person on the Schedule of Benefits, for whom an enrollment form has been accepted by the Insurer and required Premium has been paid when due and for whom coverage under this Plan remains in force. May include Insured Spouse and/or Insured Dependent covered under this Plan as Eligible Dependents. An Insured Person may also be referenced as You or Your.

Intercollegiate Sport: A sport that:

  1. has been accorded varsity status by the participating School;
    1. is administered by such School’s department of intercollegiate athletics for which the eligibility of the participating student athlete is reviewed and certified in accordance with the applicable intercollegiate sports organization's legislation, rules or regulations;
    2. entitles qualified participants to receive the participating School’s official awards;
      1. Includes travel, only within the contiguous United States, including Alaska and Hawaii and only directly and without interruption between home, School and the premises of the Intercollegiate Sporting event.

Interscholastic Sport: A sport played between secondary schools.

Intramural Sport: A sport that:

  1. is approved by the sports director or athletic director of the School; and
  2. involves only students at the same School; and
  3. takes place within the walls, boundaries and grounds of said School
  4. or participation in an approved Intercollegiate tournament, on campus or approved by the Policyholder.

Lifetime Maximum: Payment of Medical Expense benefits is subject to a lifetime aggregate maximum per individual Insured Person as indicated in the Schedule of Benefits, as long as the Plan remains in force. The Lifetime Maximum includes all benefit maximums specified in the Plan, including those specified in the Schedule of Benefits.

Lookback Period: The amount of time that will be reviewed to determine if a claim is related to a Pre-Existing Condition.

Master Policy: The agreement between the Insurer and the Fairmont Specialty Trust.

Maternity Care: Prenatal care, childbirth, postnatal care, miscarriage and premature birth, and Complications of Pregnancy.

Maximum Benefit: The payment specified in the Schedule of Benefits, for specific services, which is the maximum amount payable by Insurer per person, regardless of the actual or Allowable Charge. This is after the Insured Person has met his obligations of Deductible, Coinsurance, Copayments and any other applicable costs.

Medical Emergency: A sudden, unexpected, and unforeseen event caused by an Illness or Injury that manifests itself by symptoms of sufficient severity that a prudent layperson would reasonably expect that failure to receive immediate medical attention would place the health of the person in serious jeopardy.

Medical Identification Card: The card provided to each Insured Person. This card contains limited benefit information including the Effective Date of coverage, as well as contact information for submitting claims and emergency medical treatment.

Medically Necessary: A service or supply is necessary and appropriate for the diagnosis or treatment of an Illness or Injury based on generally accepted current medical practice. A service or supply will not be considered as Medically Necessary if:

  1. it is provided only as a convenience to the Insured Person or provider;
  2. it is not the appropriate treatment for the Insured Person's diagnosis or symptoms;
    1. it exceeds (in scope, duration or intensity) that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment.

The fact that any particular Physician may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service or supply Medically Necessary.

Nurse: A licensed graduate registered nurse (R.N.) or a licensed practical nurse (L.P.N.) who is not:

  • the Insured Person,
  • an Immediate Family Member of either the Insured Person or the Insured Person's spouse, or
  • a member of the same household.

Optician: A person or business licensed by the state which renders services to manufacture, grind and or dispense vision lenses and vision frames prescribed by either an Optometrist or an Ophthalmologist, who is not:

  • the Primary Insured,
  • an Insured Dependent,
  • an Immediate Family Member, or
  • retained by the Policyholder.

Outpatient: Services, supplies or equipment received while not an Inpatient in a Hospital, or other health care facility, or overnight stay.

Out-of-Network Provider: Any Hospital, Physician, or other provider of health care services who has not agreed to any pre-arranged fee schedules.

Out-of-Pocket Maximum: The maximum dollar amount an Insured Person is responsible to pay during a Period of Insurance. After an Insured Person has reached the Out-of-Pocket Maximum, the Plan covers benefits at 100% for the remainder of the Period of Insurance. Some benefits, however, will always remain payable at the percentage shown in the Schedule of Benefits. The Out-of-Pocket Maximum is met by Coinsurance. Copayments are not applied to the Out- of-Pocket Maximum. Penalties and amounts above the Usual, Customary, and Reasonable Charge do not count toward the Out-of-Pocket Maximum. The Out-of-Pocket Maximum is shown in the Schedule of Benefits. In no instance will We pay more than the Lifetime Maximum Benefit as shown in the Schedule of Benefits.

Period of Insurance: The start and end date for which insurance coverage is in effect as shown on the Medical Identification Card. When multiple Summary of Benefits are issued during a School Year, the Maximum Benefit is an accumulation of all Summary of Benefits issued during the School Year.

Physician: A licensed health care provider and/or Licensed Therapist practicing within the scope of their license and rendering care and treatment to the Insured Person that is appropriate for the condition and locality, and who is not:

  1. the Insured Person;
  2. an Immediate Family Member of either the Insured Person or the Insured Person's Spouse;
  3. a person living in the Insured Person's household; member of the same household
  4. a person employed or retained by the Policyholder; or
  5. a person providing homeopathic, aroma-therapeutic, or herbal therapeutic services.

Plan: The agreement between the Insurer and the Policyholder. The Plan includes the Master Policy, the Summary of Benefits, the Schedule of Benefits, and the application.

Pre-Authorization: A process by which an Insured Person obtains written approval for certain medical procedures or treatments from the Insurer prior to the commencement of the proposed medical treatment. Certain medical procedures will require the Pre-Authorization process to be followed in order for the service to be covered and to maximize the benefits of the Insured Person.

Pre-Existing Condition: A pre-existing condition is a disease or physical condition for which medical advice or treatment has been received within 12 months immediately prior to becoming covered under the Plan

Preferred Allowance: Refers to the amount an In-Network Provider will accept as payment in full for covered medical expenses.

Preferred Provider: The providers and Hospitals who have contracted with a Preferred Provider Organization to provide specific medical care at negotiated prices.

Preferred Provider Organization (PPO): Refers to a participating Provider, such as Hospital, clinic or Physician that has entered into an agreement to provide health services to Insured Persons.

Premium(s): The consideration owed by the Insured Person to the Insurer in order to secure benefits for its Insured Persons under this Plan.

Prescription Medications: Prescription medications are medications which are prescribed by a Physician, and which would not be available without such prescription. Certain treatments and medications, such as vitamins, herbs, aspirin, cold remedies, medicines, Experimental or Investigative medications, or medical supplies even when recommended by a Physician, do not qualify as prescription medications.

Professional Sports: Activities in which the participants receive payment for participation, this does not include participants in National Collegiate Athletic Association (NCAA) or National Association of Intercollegiate Athletics (NAIA).

Provider:  The organization or person performing or supplying treatment, services, supplies or medications.

Qualifying Insurance Coverage: Insurance coverage of an individual under any of the following:

  1. A group health plan.
  2. Individual or group health coverage.
  3. Medicare.
  4. Medicaid.
    1. Medical and dental care for members and certain former members of the uniformed services and for their Dependents.
    2. A medical program of the federal Indian health service or tribal organization.
    3. A state health benefits risk pool.
    4. The Federal Employees Health Benefits Program.
    5. The State Children’s Health Insurance Program (S-CHIP).
      1. Health plans established and maintained by foreign governments or political subdivisions and by the U.S. government.
      2. Any public health benefit program provided by state, country, or other political subdivision of a state.
      3. A health benefit plan under the federal Peace Corps Act.

Rehabilitation: Therapeutic services designed to improve a patient’s medical condition within a predetermined time period through establishing a maintenance program designed to maintain the patient’s current condition, prevent it from deteriorating and assist in recovery.

Rehabilitation Facility: A legally operating institution or part of an institution which has a transfer agreement with one or more Hospitals and which:

  • is  primarily  engaged  in  providing  comprehensive  multi-disciplinary  physical  rehabilitative  services  or

rehabilitation inpatient care, and

  • is duly licensed by the appropriate government agency to provide such services , and
    • is required to be accredited by the Joint Commission on Accreditation of Health Care Organizations or the Commission on Accreditation of Rehabilitation Facilities.

A Rehabilitation Facility does not include institutions which provide only minimal care, custodial care, care for the terminally ill, part-time care, or services or facilities for drug abuse or alcoholism.

Repatriation or Local Burial: This is the expense of preparation and the air transportation of the mortal remains of the Insured Person from the place of death to their Home Country, or the preparation and Local Burial of the mortal remains of an Insured Person who dies outside their Home Country. This benefit is excluded where death occurs in their Home Country.

Schedule of Benefits: The summary description of the benefits, payment levels and Maximum Benefits, provided under this Plan.

School: The college or university where the Insured Person is enrolled. The School must be licensed or accredited, as applicable, by the jurisdiction where it is located, to provide the care, education or training for which the Insured Person is enrolled.

School Year: The 12months period when the educational institution begins classes, usually starting in late summer and may conduct classes on a quarterly, semester, or other regularly scheduled basis.

Skilled Nursing Facility: means an institution which meets all the following requirements:

  • it must be operated pursuant to law,
  • it must be primarily engaged in providing, in addition to room and board accommodations, nursing services

under a licensed Physician’s supervision,

  • Registered or License Practical Nurses must supervise 24 hours a day, and
  • a daily record for each patient must be maintained.

This definition does not include:

  1. Rest home or similar facility,
  2. Home or facility for the aged,
  3. Home or facility for drug addicts and alcoholics,
  4. Home or facility for care and treatment of mental diseases and disorders, or
  5. Home or facility for custodial or educational care.

Spouse: means the Insured Person's lawful spouse or domestic partner.

Student Health Center: A facility that meets all of the following requirements: 1) located in or near a School facility and open during School hours; 2) organized through the School, community, and health care Provider relationships; and 3) staffed by qualified health care Providers.

Subrogation: Circumstances under which the Insurer may recover expenses for a claim paid out when another party should have been responsible for paying all, or a portion of that claim.

Summary of Benefits: The document provided to the Insured Person that includes the Schedule of Benefits and the terms of the Master Policy issued to the Trust.

Terrorism: Terrorist activity means an act, or acts, of any person, or groups of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization or government.

Trip: Round trip travel by air, land, or sea from the Insured’s Home Country.

Usual, Customary and Reasonable Charge (UCR): Fees and prices generally charged within the locality where performed for Medically Necessary services and supplies required for treatment of cases of comparable severity and nature.

Vision Examination: An examination of principal vision functions. A Vision Examination includes but is not limited to, case history, examination for pathology or anomalies, job visual analysis, refraction, vision field testing and tonometry, if indicated. The exam will be consistent with the community standards, rules and reg ulations of the jurisdiction in which the provider practice is located administered by an Optician.

Waiting Period: The period of time beginning with the Insured Person’s Effective Date, during which limited, or no benefits are available for particular services. After satisfaction of the Waiting Period, benefits for those services become available in accordance with this Plan.

We, Us, Our and Insurer: Crum & Forster, SPC

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.      AIDS/HIV: Acquired Immune Deficiency Syndrome (AIDS), AIDS related Complex Syndrome (ARC), HIV positive, all secondary diseases, and all sexually transmitted diseases
  2. 2.      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. 3.      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. 4.      Breast reduction: All services and treatments,
      1. 5.      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. 6.      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. 7.      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. 8.      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. 9.      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. 10.  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. 11.  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. 12.  Hernia: Treatment of a hernia, including sports hernia whether or not caused by a covered Accident,
  1. 13.  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. 14.  Illegal Activities: Injuries or Illnesses resulting or arising from or occurring during the commission of an assaultor felony,
  1. 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.
  1. Professional Sports: Any loss sustained while participating in or training for any sport or activity performed for financial gain.
  2. Self-Inflicted Illnesses, Injuries, or Exceptional Danger: a) Treatment for any conditions as a result of self-inflicted Illnesses or injuries, suicide or attempted suicide, while sane or insane, b) 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.
  1. Sports and Hazardous Activities: Losses resulting from: 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.
  2. Substance Abuse: Any loss directly or indirectly resulting from alcohol or illegal drug abuse or other addiction, or any drugs or medicines that are not taken in the dosage or for the purpose prescribed.
  3. 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.

The “Pre-existing Condition Waiting Period” is 6 months. If you receive treatment or service for a PreExisting Condition: a) No benefits will be paid for such condition until the day after a 6 consecutive month period has passed from your effective date; and b) The plan will pay only for Covered Expenses incurred after such 6 consecutive month period.

Pre-Existing Condition means an Injury, Sickness, disease, or other condition during the 365 day period immediately prior to the date the Plan Participant’s coverage is effective 1) received or received a recommendation for a test, examination, or medical treatment for a condition which first manifested itself, worsened or became acute or had symptoms which would have prompted a reasonable person to seek diagnosis, care or treatment; or 2) took or received a prescription for drugs or medicine. Item (2) of this definition does not apply to a condition which is treated or controlled solely through the taking of prescription drugs or medicine and remains treated or controlled without any adjustment or change in the required prescription throughout the 365 day period before coverage is effective under the Plan Participant’s Plan.

United States only:
  • In-Network Preferred Provider: This tier consists of Preferred Providers and Hospitals who have a contract with the Preferred Provider Organization to provide specific medical care and that have agreed to accept a Preferred Allowance as payment in full for the specific service. The Medical Identification Card contains the logo for the network. Present it to the Physician or Hospital.
  • Out-of-Network Provider: Utilizing Providers that are Out-of-Network is a more costly financial option for the Insured Person. The Insurer reimburses such Providers up to an Allowable Charge as determined by the Insurer. The Provider may bill the Insured Person the difference between the amounts reimbursed by the Insurer and the Provider’s billed charge. Additionally, the Insured Person will pay a Coinsurance amount that is higher than if an In-Network Provider were used.
  • Out-of-Network Area: When there are no network Providers located within a 30-mile radius ofYour local residence, charges from such Providers will be treated the same as a U.S. In-Network Preferred Provider.

The Insurer retains the right to limit or prohibit the use of Providers which significantly exceed Allowable Charges.

Cancellation

The Insurer may at any time terminate an Insured Person, or modify coverage to different terms, if the Insured Person has at any time:

  • Misled the Insurer by misstatement or concealment,
  • Knowingly claimed benefits for any purpose other than are provided for under this Plan,
  • Agreed to any attempt by a third party to obtain an unreasonable pecuniary advantage to the Insurer’s detriment,
  • Failed to observe the terms and conditions of this Plan or failed to act with utmost good faith.

 If the Insured Person cancels the insurance coverage after it has been issued or reinstated, the Insurer will only refund Premium on a pro rata basis if the Insured Person provides proof of other health coverage or other valid reason for cancellation as determined by the Company or its Administrator. Premium refunds will not be considered if a claim has been filed during the Period of Insurance.

Cancel

Cancellation

The Insurer may at any time terminate an Insured Person, or modify coverage to different terms, if the Insured Person has at any time:

  • Misled the Insurer by misstatement or concealment,
  • Knowingly claimed benefits for any purpose other than are provided for under this Plan,
  • Agreed to any attempt by a third party to obtain an unreasonable pecuniary advantage to the Insurer’s detriment,
  • Failed to observe the terms and conditions of this Plan or failed to act with utmost good faith.

 If the Insured Person cancels the insurance coverage after it has been issued or reinstated, the Insurer will only refund Premium on a pro rata basis if the Insured Person provides proof of other health coverage or other valid reason for cancellation as determined by the Company or its Administrator. Premium refunds will not be considered if a claim has been filed during the Period of Insurance.

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:

Web:

Mail:

Fax:

Email:

www.gbg.com

GBG Administrative Services, Inc.

P.O. BOX 211008 Eagan, MN 55121 USA

+1 949 271 2330

eclaims@gbg.com

 

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:

 

Toll Free

Phone

Email

+1.866.914.5333

(within the U.S. and Canada)

+1.786.814.4125

(outside the U.S. and Canada)

complaints@gbg.com

 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:

 

Toll Free

Phone

Email

+1.877.916.7920

(within the U.S. and Canada)

+1.949.916.7941

(outside the U.S. and Canada)

customerservice@gbg.com

 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.

If You conclude Your relationship with the Company, the Company will continue to safeguard Your privacy in accordance with the standards described in this notice. The Company maintains physical, electronic and procedural safeguards to protect non-public personal information.

How to contact Us

If you have any questions about this Privacy Notice or about how We use the information We collect, please contact Us at:

Crum & Forster SPC Caribbean Plaza, 2nd 878 West Bay Road

P.O. Box 1159

Grand Cayman KYI-1102