Applicant Eligibility	Non-US citizen legally departed the Country of Residence and legally entered the Destination Country (United States, Canada, or Mexico) on an eligible nonimmigrant visa or similar arrangements. Green card holders of the United States and lawful permanent residents of the Destination Country are not eligible for this coverage. This plan must be purchased prior to departing the Country of Residence, including any future repurchases.
Minimum Age	Individual at least fourteen (14) days old
Minimum Age	Individual age 80 and older.
Period of Coverage	Minimum of ninety (90) days and no more than a maximum of twelve (12) months.
Destination Country	United States, Canada or Mexico
Area of Coverage	United States, Canada or Mexico

All the geographical areas that the Insured Person is traveling to or within other than the primary place of residence declared on the Application. For the purposes of this insurance, the Destination Country is either the United States, Canada or Mexico.

ELIGIBILITY: If an Insured Person is not eligible, this Certificate is void ab initio and all Premium paid will be refunded. In order to be eligible and qualified for coverage under this insurance, a person must meet all of the following requirements:

(1)    (1) complete and sign an Application as the Insured Person (or be listed thereon by proxy as an applicant and proposed Insured Person), and/or as the Insured Person’s Spouse, Child and/or Grandchild

(2)    pay the required Premium on or before the Effective Date of Coverage

(3)    receive written acceptance of their Application from the Company

(4)    be an individual at least fourteen (14) days old

(5)    (5) on the Effective Date, must have legally departed the Country of Residence and legally entered the Destination Country (United States, Canada, or Mexico) on an eligible nonimmigrant visa or similar arrangements. Green card holders of the United States and lawful permanent residents of the Destination Country are not eligible for this coverage.

(6)    not have established a permanent residency in the Destination Country

(7)    this plan must be purchased prior to departing the Country of Residence, including any future repurchases

(8)    purchased a minimum of ninety (90) days and no more than a maximum of twelve (12) months.

TERMINATION OF MASTER POLICY: The Master Policy can be terminated at any time by either the Company or the Assured by giving at least thirty (30) days written notice to the other and to the Insured Person. Such termination will have no effect on this Certificate prior to the date of the termination or on eligible coverage or benefits under this insurance accrued prior thereto. No additional Certificates will be issued or further Applications accepted for the plan after the date the Master Policy is terminated.

TERMINATION OF COVERAGE FOR INSURED PERSONS: Coverage and benefits for the Insured Person under this insurance will terminate effective at 12:01 AM EST on the earliest of the following dates:
(a)    the date the Master Policy is terminated pursuant to the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF MASTER POLICY provision
(b)    the next day following the end of the coverage period for which Premium has been fully and timely paid
(c)    the termination date as shown on the Declaration for this Certificate
(d)    the date the Insured Person first fails to meet or no longer meets the eligibility requirements for this insurance as set forth in the Master Policy and outlined in this Certificate
(e)    the date the Insured Person returns to their Country of Residence
(f)    the date the Company, at its sole option, elects to cancel from this plan all Insured Persons of the same sex, age, class or geographic location as the Insured Person, provided the Company gives no less than thirty (30) days advance written notice by mail to the Insured Person’s last known residence or mailing address of its intent to exercise such option
(g)    the cancellation date specified by the Company pursuant to the CONDITIONS AND GENERAL PROVISIONS,
CANCELLATION BY INSURED PERSON provision
(h)    the cancellation date specified by the Insured Person pursuant to the CONDITIONS AND GENERAL PROVISIONS,
NON-RENEWAL; AMENDMENTS provision
(i)    the date specified by the Company in any notice of cancellation, forfeiture or rescission issued pursuant to or as a result of the circumstances described in the MISREPRESENTATION, FRAUDULENT CLAIMS and RIGHT OF RECOVERY subparagraphs of the CONDITIONS AND GENERAL PROVISIONS, or as otherwise permitted by the Terms of this insurance.
Coverage for the Insured Person shall remain in full force and effect unless terminated pursuant to this provision, except as otherwise provided in the Master Policy, the Declaration, or this Certificate.

OTHER INSURANCE: The Company shall not be liable or obligated to provide any coverage or benefits or to pay or reimburse any claim under this insurance if there is any other insurance, membership benefit, workers’ or workplace compensation coverage program or other government programs, reimbursement or indemnification coverage, right of contribution, recoupment or recovery, contract, or any other third-party obligation or liability for provision of benefits (“Other Coverage”) that would, or would but for the existence of this insurance, be available or obligated to provide such benefit or to pay or reimburse or provide indemnity for such claim, except in respect of any excess beyond the amount payable or provided under such Other Coverage had this insurance not been effected. Notwithstanding the foregoing, the Company shall not be liable or obligated to provide any benefit or to pay or reimburse any claim for any Insured Person in respect to Treatment or supplies furnished by any program or agency funded by any government or governmental authority.
The Company reserves the right to cancel any and all coverage if it is determined an Insured Person has Stacked Insurance.

DEFINITION
Stacked Insurance: Purchasing the same or like insurance product through the Company, for the same area of coverage, for the same or similar coverage period, and for the same coverage intent to increase a claims payout.

IMPORTANT NOTICE REGARDING PATIENT PROTECTION AND AFFORDABLE CARE

ACT (PPACA): This insurance is not subject to, and does not provide benefits required by, PPACA. Since January 1, 2014, PPACA has required United States citizens, United States nationals and resident-aliens to obtain PPACA compliant insurance coverage unless they are exempt from PPACA. Penalties may be imposed on persons who are required to maintain PPACA compliant coverage but do not do so.

Eligibility to purchase or renew this product, or its terms and conditions, may be modified or amended based upon changes to applicable law, including PPACA. Please note that it is solely your responsibility to determine if PPACA is applicable to you and the Company and IMG shall have no liability whatsoever, including for any penalties that you may incur, for your failure to obtain required PPACA compliant coverage.

Coverage Limit / Maximum Amount for Eligible Medical Expenses
Period of Coverage	90 days up to 12 months
Per Injury or Illness Maximum Limit As indicated on the Declaration	Through age 69: $50,000, $100,000 or $250,000 Ages 70 and older: $50,000
Area of Coverage	United States including Canada and Mexico
Benefit Plan Features
Benefit Levels	United States In-Network Canada Mexico	United States Out-of-Network
Deductible for Eligible Medical Expenses
Per Injury or Illness Deductible	$250, $500, $1,000, $2,500 or $5,000 per Insured Person, as indicated on the Declaration
Coinsurance for Eligible Medical Expenses
Coinsurance In addition to Deductible	Plan pays 75% Insured pays 25%	Plan pays 60% Insured pays 40%
Pre-certification
Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met. Emergency Medical Evacuation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION provision for complete requirements and coverage. All other Treatments & supplies: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met. Deductible is taken after reduction. Coinsurance is applied to remainder of the reduced amount. Refer to the PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification.
Pre-existing Conditions
Deductible: $1,500 per Injury or Illness (plan Deductible waived) Maximum Limit through age 69: $25,000 Maximum Limit ages 70 and older: $20,000
Inpatient or Outpatient Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Benefit	United States In-Network Canada Mexico	United States Out-of-Network
Eligible Medical Expenses	75%	60%
Physician Visits / Services	75%	60%
Urgent Care Clinic Not subject to Deductible and Coinsurance In-Network Copayment: $25 Out-of-Network Copayment: $50	100%	100%

Inpatient or Outpatient Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Benefit	United States In-Network Canada Mexico	United States Out-of-Network
Walk-in Clinic Not subject to Deductible and Coinsurance In-Network Copayment: $15 Out-of-Network Copayment: $25	100%	100%
Hospital Emergency Room Injury: Not subject to Emergency Room Deductible Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission	75%	60%
Hospitalization / Room & Board Average semi-private room rate Includes nursing services	75%	60%
Intensive Care	75%	60%
Hospital Ancillary Services Maximum Limit: $40,000 Includes laboratory, x-rays, drugs and miscellaneous services	75%	60%
Outpatient Surgical / Hospital Facility	75%	60%
Laboratory	75%	60%
Radiology / X-ray	75%	60%
Pre-admission Testing	75%	60%
Surgery	75%	60%
Reconstructive Surgery Surgery is incidental to and follows Surgery that was covered under the plan	75%	60%

 

Inpatient or Outpatient Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Benefit	United States In-Network Canada Mexico	United States Out-of-Network
Assistant Surgeon  20% of the primary surgeon’s eligible fee	75%	60%
Anesthesia	75%	60%
Durable Medical Equipment	75%	60%
Chiropractic Care Medical order or Treatment plan required	75%	60%
Physical Therapy Inpatient and Outpatient Medical order or Treatment plan required	75%	60%
Extended Care Facility Upon direct transfer from an acute care Facility	75%	60%
Home Nursing Care Provided by a Home Health Care Agency Upon direct transfer from an acute care Facility	75%	60%
Prescription Drugs Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Outpatient Prescription Drugs	75%	60%
Emergency Services NOT Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Emergency Local Ambulance Subject to Deductible and Coinsurance Injury Illness resulting in an Inpatient Hospital admission	75%	60%
Emergency Medical Evacuation Maximum Limit: $25,000 Approved in advance and coordinated by the Company	100%	100%
Emergency Reunion Maximum Limit: $100,000 Maximum days: 15 Meal maximum per day: $25 Reasonable and necessary travel costs and accommodations Approved in advance by the Company	100%	100%

 

Emergency Services NOT Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Benefit	United States In-Network Canada Mexico	United States Out-of-Network
Interfacility Ambulance Transfer Transfer must be a result of an Inpatient Hospital admission	100%	100%
Return of Minor Children Maximum Limit: $100,000 Approved in advance by the Company	100%	100%
Return of Mortal Remains Maximum Limit: $25,000 Local Burial / Cremation Maximum Limit: $5,000 Return of insured person's mortal remain to Country of Residence Approved in advance by the Company	100%	100%
Other Services NOT Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Accidental Death & Dismemberment Principal Sum Maximum Limit: $25,000 Death must occur within 90 days of the Accident	Accidental Death: 100% of Principal Sum
	Dismemberment: Accidental Loss      Percent of Principal Sum Sight of one eye 50% One hand or one foot 50% One hand and the loss of sight of one eye  100% One foot and the loss of sight of one eye  100% One hand and one foot  100% Both hands or both feet  100% Sight of both eyes  100%
Dental Treatment Subject to Deductible and Coinsurance Limit: $300 (Unexpected pain or Treatment due to an Accident)	75%	75%
Traumatic Dental Injury Subject to Deductible and Coinsurance Treatment at a Hospital due to an Accident Additional Treatment for the same Injury rendered by a Dental Provider will be paid at 100%	75%	60%

TELADOC RIDER Inpatient or Outpatient Services Not subject to Deductible and Coinsurance
Benefit	Limits
Teladoc Consultation	Mental or Nervous Disorders are not covered Coverage for a Teladoc Consultation is not a determination that any specific condition discussed, raised or identified during such consultation is covered under this insurance. The Company reserves the right to decline future claims relating to or arising from any condition discussed, raised or identified during a Teladoc Consultation where the Illness or Injury is otherwise excluded under this Certificate of Insurance.

CELLULAR PHONE RIDER Other Services Subject to Deductible unless otherwise noted Subject to the Specified Perils and limited to Repair and Replacement Maximum Limits per Period of Coverage or if indicated, per Lifetime
Covered Cellular Phone Retail Value	Repair Deductible per phone and per claim	Irreparable Deductible per phone and per claim	Replacement Deductible per phone and per claim
Up to $500	$49	$99	$199
$500 and above	$99	$199	$299
Every effort will be made to fix the Insured Person’s damaged Cellular Phone. If the Cellular Phone is not repairable, the irreparable Deductible will apply. The above Deductibles shall be payable by the Insured Person when the claim is approved. Please note that the Deductible is not refundable.

ELIGIBLE MEDICAL EXPENSES: Subject to the Terms of this insurance, and the insurance plan shown in the Declaration, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY for the following costs, Charges and expenses incurred by the Insured Person during the Period of Coverage with respect to an Illness or Injury suffered or sustained by the Insured Person during the Period of Coverage and while this Certificate is in effect, so long as the Illness or Injury is covered under this Certificate, Charges are Usual, Reasonable and Customary, and Charges are incurred for Treatment or supplies that are Medically Necessary (“Eligible Medical Expenses”):

(1) Charges incurred at a Hospital for:

(a) daily room and board and nursing services not to exceed the average semi-private room rate. A private room will be considered when no semi-private room is available or if medical necessity warrants this type of room. The private room rate is not to exceed the average private room rate.

(b) daily room and board and nursing services in an Intensive Care Unit

(c) Ancillary Services including laboratory, x-rays, drugs and miscellaneous services, up to the amount shown in the BENEFIT SUMMARY

(d) use of operating, Treatment or recovery room

(e) services and supplies that are routinely provided by the Hospital to persons for use while an Inpatient

(f) Emergency Treatment of an Injury, even if Hospital confinement is not required

(g) Emergency Treatment of an Illness; however, an additional Deductible (as shown in the BENEFIT SUMMARY) will be required unless the Insured Person is directly admitted to the Hospital as Inpatient for further Treatment of that Illness

(2) Charges incurred for Surgery at an Outpatient Surgical Facility, including services and supplies

(3) Charges by a Physician for professional services rendered, including Surgery; provided, however, that Charges by or for an assistant surgeon will be limited and covered at the rate of up to twenty percent (20%) of the Usual, Reasonable and Customary charge of the primary surgeon; and provided, further, that the standby availability of a Physician or surgeon will not be deemed to be a professional service and is not eligible for coverage

(4) Charges incurred for:

(a) dressings, sutures, casts or other supplies that are Medically Necessary

(b) diagnostic testing using Radiology, ultrasonography or laboratory services. Laboratory services billed for professional component fees are covered if the pathologist has direct involvement in providing a written report or verbal consultation for specimen-specific pathology services

(c) Implant devices that are Medically Necessary; however, any Implants provided outside the PPO network are limited to a payment of no more than one hundred fifty percent (150%) of the established invoice price and/or list price for that item

(d) basic functional artificial limbs, eye or larynx or breast prostheses, but not the replacement or repair thereof

(e) reconstructive Surgery when the Surgery is incidental to and follows Surgery that was covered hereunder

(f) hemodialysis for the Treatment of acute renal failure only and the Charges by a Hospital for processing and administration of blood or blood components

(g) oxygen and other gases and their administration

(h) anesthetics and their administration by a Physician

(i) Outpatient drugs that require a prescription by a Physician for Treatment of Illness or Injury, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of ninety (90) days of any one (1) prescription

(j) care in a licensed Extended Care Facility upon direct transfer from an acute care Hospital

(k) Home Nursing Care in bed by a qualified licensed professional, provided by a Home Health Care Agency upon direct transfer from an acute care Hospital

(l) Emergency Local Ambulance Transport necessarily incurred in connection with:

(i) an Injury

(ii) an Illness resulting in Hospital confinement as an Inpatient

(m) Interfacility Ambulance Transfer must be a result of an Inpatient Hospital Admission, Medically Necessary and from one licensed health care Facility to another licensed health care Facility via air or land ambulance

(n) chiropractic services prescribed by a Physician and performed by a professional chiropractor and necessarily incurred to continue recovery from a covered Injury or covered Illness; services include manipulations, x-rays and laboratory tests ordered by the chiropractor

(o) Inpatient and Outpatient physical therapy prescribed by a Physician and performed by a professional physical therapist and necessarily incurred to continue recovery from a covered Injury or covered Illness

(p) Durable Medical Equipment, as defined herein, deemed to be Medically Necessary

(q) Emergency Treatment of Pregnancy, as defined under this insurance

(r) ectopic Pregnancy

(5) Charges incurred for Teleconsultation or Virtual Physician Visit

(6) Charges incurred for Treatment at an Urgent Care Clinic

(7) Charges incurred for Treatment at a Walk-in Clinic

(8) Charges for Treatment of an Injury to the foot due to an Accident covered hereunder

(9) Charges for Treatment of an Illness for which foot Surgery is Medically Necessary and determined to be the only appropriate method of Treatment

(10) Charges for Treatment following Traumatic Dental Injury from a covered Accident that resulted in physical Injury to the Insured Person

(11) Charges for Dental Treatment as follows up to the amount shown in the BENEFIT SUMMARY:

(a) Charges for necessary Dental Treatment of Unexpected pain to sound natural teeth

(b) Charges incurred for non-emergency Dental Treatment necessary due to an Accident covered hereunder

(12) Charges incurred relating to Pre-existing Conditions, as defined herein, subject to the amount shown in the BENEFIT SUMMARY

(13) Charges for value-added tax (VAT) or like tax incurred on Eligible Medical Expenses.

B. ACCIDENTAL DEATH AND DISMEMBERMENT:

(1) ACCIDENTAL DEATH: Subject to the Terms of this insurance, and in the event the Insured Person has an Accident during the Period of Coverage that results in death during the Period of Coverage, the Company will pay an Accidental Death benefit in the amount of the Principal Sum shown in the BENEFIT SUMMARY. The Insured Person’s death must occur within ninety (90) days of the Accident and result, directly and independently of all other causes, from an accidental bodily Injury that is unintended, unexpected and unforeseen. The bodily Injury must be evidenced by a visible contusion or wound, except in the case of accidental drowning. The bodily Injury must be the sole cause of death. The Company will pay the benefit owed upon proper application therefor, in the following order:

(a) to the beneficiary designated in writing by the Insured Person

(b) to the Insured Person’s closest surviving Relative

(c) the Insured Person’s estate

(d) to a claimant entitled to payment under applicable small estate affidavit laws.

(2) DISMEMBERMENT: Subject to the Terms of this insurance and if the Insured Person has an Accident during the Period of Coverage which results in a loss identified in the BENEFIT SUMMARY within ninety (90) days from the date of the Accident and during the Period of Coverage, the Company will reimburse the Insured Person the applicable loss/dismemberment shown in the BENEFIT SUMMARY.

The maximum benefit payable for all dismemberments or losses resulting from any one (1) Accident or Injury shall not exceed the Principal Sum shown in the BENEFIT SUMMARY for Accidental Death.

The loss of a hand or foot means the complete severance at or above the wrist or ankle joint. The loss of sight means the entire and irrecoverable loss of sight. The Insured Person’s dismemberment must result, directly and independently of all other causes, from an accidental bodily Injury which is unintended, unexpected, and unforeseen. The bodily Injury must be evidenced by a visible contusion or wound. The bodily Injury must be the sole cause of dismemberment.

I. EMERGENCY MEDICAL EVACUATION:

(1) Subject to the applicable Maximum Limit set forth in the BENEFIT SUMMARY, and the other Terms of this insurance, including the EXCLUSIONS provision and the CONDITIONS AND RESTRICTIONS subparagraph below, the Company will reimburse the Insured Person for the following transportation costs, when the Company or Plan Administrator arranges such transportation, and expenses incurred by the Insured Person arising out of or in connection with an Emergency Medical Evacuation occurring while this Certificate is in effect and during the Period of Coverage:

(a) Emergency air transportation to a suitable airport nearest to the Hospital where the Insured Person will receive Treatment

(b) Emergency ground transportation necessarily preceding Emergency air transportation and from the destination airport to the Hospital where the Insured Person will receive Treatment

(c) Return ground and air transportation, upon medical release by the attending Physician, to the country where the evacuation initially occurred or to the Insured Person’s Country of Residence, at the Insured Person’s option.

(2) CONDITIONS AND RESTRICTIONS: To be eligible for coverage for Emergency Medical Evacuation benefits, the Insured Person must be in compliance with all Terms of this insurance. The Company will provide Emergency Medical Evacuation benefits only when the condition, Illness, Injury or occurrence giving rise to the Emergency Medical Evacuation is covered under the Terms of this insurance. The Company will provide Emergency Medical Evacuation benefits only when all of the following conditions and restrictions are met:

(a) Medically Necessary Treatment cannot be provided locally

(b) transportation by any other means or methods would result in loss of the Insured Person’s life or limb within twenty- four (24) hours, based upon a reasonable medical certainty

(c) Emergency Medical Evacuation is recommended by the attending Physician who certifies to the matters in subparagraphs (a) and (b), above

(d) Emergency Medical Evacuation is agreed to by the Insured Person or a Relative of the Insured Person

(e) Emergency Medical Evacuation is provided by designated, licensed, qualified, professional emergency personnel acting within the scope of such license and approved in advance and all arrangements are coordinated by the Company

(f) the condition, Illness, Injury or occurrence giving rise to the need for the Emergency Medical Evacuation:

(i) occurred outside the Insured Person’s Country of Residence suddenly, Unexpectedly, and spontaneously, and without: (1) advance warning, or (2) advance Treatment, diagnosis or recommendation for Treatment by a Physician, or (3) prior manifestation of symptoms or conditions that would have caused a reasonably prudent person to seek medical attention prior to the onset of the Emergency

(ii) was not a Pre-existing Condition.

(g) The Company will cover reimbursement for the above-described costs and expenses and will arrange Emergency Medical Evacuation only to the nearest Hospital that is qualified to provide the Medically Necessary Treatment to prevent the Insured Person’s loss of life or limb.

The Insured Person may select a different Hospital in their Country of Residence at their option, but in such event the Insured Person shall be solely responsible for all costs and expenses in excess of the amounts that would have been incurred had the Insured Person used the nearest qualified Hospital. If a Hospital other than the nearest qualified Hospital is selected by the Insured Person, then the attending Physician, Insured Person or a Relative of the Insured Person shall certify to the Company the Insured Person’s understanding and acknowledgement of such responsibility for excess costs and expenses in addition to the matters set forth in the CONDITIONS AND RESTRICTIONS subparagraph, above. In all cases the Company will make the necessary arrangements for the Emergency Medical Evacuation and will use its best efforts to arrange with independent, third-party contractors any Emergency Medical Evacuation within the least amount of time reasonably possible.

By acceptance of this Certificate and request for Emergency Medical Evacuation benefits hereunder, the Insured Person understands, acknowledges and agrees that the timeliness, duration, occurrences during and outcome of an Emergency Medical Evacuation can be directly and indirectly affected by events and/or circumstances that are not within the supervision or control of the Company, including but not limited to: the availability, limitations, physical condition, reliability, maintenance and training schedules and procedures and performance or non-performance of competent transportation equipment, supplies and/or staff of such third-party contractors; delays or restrictions on flights or other modes or means of transportation caused by mechanical problems, government officials, telecommunications problems, non-availability of routes, and/or other travel, geographical or weather conditions; and other acts of God and unforeseeable and/or uncontrollable occurrences.

The Insured Person agrees to release and to hold the Company, the Plan Administrator and their agents and representatives harmless from, and agrees that the Company, the Plan Administrator and their agents and representatives shall not be held liable or responsible for, any delays, losses, damages, further Injuries or Illnesses, or any other claims that arise from or are caused in whole or in part by the acts or omissions of such independent third- party contractors or their agents, employees or representatives, or that arise from or are caused in whole or in part by any acts, omissions, events or circumstances that are not within the direct and immediate supervision and control of the Company, the Plan Administrator and/or their authorized agents and representatives, including without limitation the events and circumstances set forth above.

The Insured Person further agrees that upon seeking an Emergency Medical Evacuation, he or she will cooperate fully as required by the CONDITIONS AND GENERAL PROVISIONS, COOPERATION provision. Failure to so cooperate and/or failure to use or accept Emergency Medical Evacuation once it has been arranged by the Company or Plan Administrator will require the Insured Person to reimburse the Company for costs incurred for any Emergency Medical Evacuation that was arranged, but not used, by the Insured Person. Furthermore, the Insured Person may be required to arrange for payment of any subsequent Emergency Medical Evacuation and seek reimbursement thereafter for eligible costs associated with that subsequent Emergency Medical Evacuation.

J. EMERGENCY REUNION:

(1) Subject to the Terms of this insurance, including without limitation the CONDITIONS AND RESTRICTIONS subparagraph below, Emergency Reunion expenses will be reimbursed to an Insured Person as outlined in the BENEFIT SUMMARY, in cases where there has been an Emergency Medical Evacuation covered under the Terms of this insurance. Subject to the applicable Deductible and Coinsurance and other limits and sub-limits as specified in the BENEFIT SUMMARY, and subject to the CONDITIONS AND RESTRICTIONS subparagraph below, the following costs and expenses incurred in respect of travel by a Relative or friend of the Insured Person will be reimbursable to the Insured Person upon the recommendation and prior approval of the Company:

(a) the cost of a round-trip economy commercial airline ticket for one (1) Relative or friend from the airport nearest to the location of the Relative or friend at the time of the Emergency to the airport serving the area where the Insured Person is Hospitalized as a result of the Emergency or is to be Hospitalized as a result of the Emergency Medical Evacuation (to be determined pursuant to the Terms of the CONDITIONS AND RESTRICTIONS subparagraph, below), and return from whichever of such locations is actually selected to the point of the original departure

(b) reasonable and necessary travel costs, meals (up to the amount shown in the BENEFIT SUMMARY), transportation and accommodation expenses incurred in relation to the Emergency Reunion (but excluding entertainment).

(2) CONDITIONS AND RESTRICTIONS:

(a) the allowable maximum coverage for the Emergency Reunion shall not exceed fifteen (15) days, including travel days, and all costs and expenses incurred beyond fifteen (15) days shall be retained for the sole account and responsibility of the Insured Person, Relative or friend

(b) the Emergency Reunion must be due to an Emergency Medical Evacuation covered under the Terms of this insurance

(c) the Insured Person must be so seriously ill that the attending Physician deems it necessary and recommends the presence of a Relative or friend at either the location where the Insured Person is being evacuated from or the destination of the Emergency Medical Evacuation, whichever is considered by the attending Physician and the Company to be the more reasonable

(d) all Emergency Reunion travel, transportation and accommodation arrangements and benefits must be approved in advance by the Company in order to be eligible for coverage under this insurance

(e) the Insured Person, Relative and/or friend must submit to the Company upon completion of the Emergency Reunion travel legible and verifiable copies of all paid receipts for the travel and transportation costs and expenses so incurred for which reimbursement is sought.

K. RETURN OF MINOR CHILDREN: Subject to the Terms of this insurance, in the event the Insured Person is Hospitalized for a covered Injury or Illness as an Inpatient or dies during the Period of Coverage and at the time of such Hospitalization the Insured Person was traveling alone with a Child, the Company will reimburse the Insured Person up to the amount shown in the BENEFIT SUMMARY for the cost of a one-way economy commercial airline ticket to return the Child to their Country of Residence, including such economy commercial airline ticket cost for a chaperone if necessary and required by the airline for the safety of the Child, subject to the following conditions and limitations:

(1) the Insured Person must be outside the Country of Residence at the time of the Hospitalization as an Inpatient

(2) the return of the Child must occur during the Insured Person’s Hospitalization

(3) reimbursable costs are only for a one-way economy commercial airline ticket from the airport nearest to the Child at the time of the Insured Person’s Hospitalization to the airport within the Child’s Country of Residence

(4) all travel and transportation arrangements for the Child must be approved in advance by the Company in order to be eligible for coverage under this insurance

(5) the Company will deduct from the return transportation benefits payable hereunder the value, if any, of the unused commercial airline return ticket(s) possessed by or for the benefit of the Child at the time of the Insured Person’s Hospitalization. The Insured Person and/or the Child must first attempt to receive credit for or deduct toward the costs of the return trip.

The Company will not provide any benefits, reimbursements or coverages for any costs or expenses incurred by the Insured Person and/or by the Child for a return trip, if any, to the original location of the Child at the time of the Hospitalization.

L. RETURN OF MORTAL REMAINS: In the event of the death of the Insured Person during the Period of Coverage as a result of an Illness or Injury covered under this insurance while the Insured Person is outside of their Country of Residence, the Company will reimburse the authorized personal representative or the estate of the Insured Person up to the amount shown in the BENEFIT SUMMARY for the costs and expenses incurred to return the Insured Person’s Mortal Remains to their Country of Residence and thereafter to the place of burial or other final disposition (but not including any costs of burial or other disposition); provided, however, that the Company must approve all costs and expenses related to the return of the Insured Person’s Mortal Remains in advance as a condition to the availability of this benefit; or up to the amount shown in the BENEFIT SUMMARY for preparation, local burial or cremation of the Insured Person’s Mortal Remains at the place of death in accordance with the commonly accepted cultural and religious beliefs practiced by the Insured Person. Coverage is not provided for burial and cremation costs incurred for religious practitioners, flowers, music, food or beverages.

M. DEFINITIONS: Certain words and phrases used in this Certificate are defined below. Other words and phrases may be defined elsewhere in this Certificate, including where they are first used.

Accident: An Unexpected occurrence directly caused by external, visible means and resulting in physical Injury to the Insured Person.

Against Medical Advice; Discharge Against Medical Advice: Against Medical Advice, or AMA, sometimes known as DAMA, Discharge Against Medical Advice, is a term used with a patient who checks themself out of a Hospital against the advice of their Treating Physician.

AIDS: Acquired Immune Deficiency Syndrome, as that term is defined by the United States Centers for Disease Control.

Amateur Athletics: An amateur or other non-professional sporting, recreational, or athletic activity that is organized, sponsored and/or sanctioned, and/or involves regular or scheduled practices, games and/or competitions. Amateur Athletics does not include athletic activities that are non-organized, non-Collision, and engaged in by the Insured Person solely for recreational, entertainment or fitness purposes.

Ancillary Services: All Hospital services for a patient other than room and board and professional services. Laboratory tests and Radiology are examples of Ancillary Services.

Application: The fully answered and signed individual or Family Application/enrollment form submitted by or on behalf of the Insured Person for acceptance into coverage under this insurance plan, which Application shall be incorporated in and become part of the Master Policy and this Certificate and the insurance contract. Any insurance agent/broker or other person or entity assigned to, soliciting, or assisting with the Application is the agent and representative of the applicant/Insured Person and is not and shall not be deemed or considered as an agent or representative for or on behalf of the Company or the Plan Administrator.

ARC: AIDS-related complex, as that term is defined by the United States Centers for Disease Control.

Assured: The Global Medical Services Group Insurance Trust, c/o RBB Financial LLC, 6368 Oxbow Way, Indianapolis, IN, 46220.

Authorization for Release of Medical Information: A written authorization by the Insured Person for health providers to release medical records and information regarding their past and current Treatment.

Certificate; Certificate of Insurance: This document as issued to the Insured Person, that describes and provides an outline and evidence of eligible coverages and benefits payable to or for the benefit of the Insured Person under the insurance contract, which includes the Master Policy, Application, Declaration and any Riders.

Charges: Any cost, fee or tax incurred for Eligible Medical Expenses incurred in the Treatment of an Injury or Illness.

Child; Children: An Insured Person who is at least fourteen (14) days old but less than eighteen (18) years of age.

Class VI: A section of a river, stream or other waterway or watercourse where the current moves with enough speed or force to meet, but not to exceed, the qualifications of Class VI as determined by the International Scale of River Difficulty or as commonly published by a local authority or government agency.

Coinsurance: The payment by or obligations of the Insured Person for payment of ELIGIBLE MEDICAL EXPENSES at the percentage specified in the BENEFIT SUMMARY contained herein and not including any applicable Deductible.

Collision Sports: A sport in which the participants purposely hit or collide with each other or inanimate objects, including the ground, with great force and limited to the following (or other similar style) sports: American football, boxing, ice hockey, lacrosse, full contact martial arts, rodeo, rugby and wrestling.

Company: The Company, as referred to in the Master Policy and this Certificate, is SiriusPoint Specialty Insurance Corporation, located at 140 Broadway, 32nd Floor, New York, New York 10005. This insurance and its risks are underwritten by the Company as the insurer and carrier, and the Company is solely obligated and liable for the coverage and benefits provided by this insurance.

Congenital Disorder: Any abnormality, deformity, disease, Illness, Injury or medical condition present at birth, whether diagnosed or not.

Convalescent: Treatment, services and supplies provided to aid in the recovery of a patient to reach a degree of body functioning to permit self-care in essential daily activities.

Copayment: The amount the Insured Person is responsible to pay for each Urgent Care or Walk-in Clinic visit.

Country of Residence: The Country of Residence is the country in which the Insured Person maintains their current primary residence or usual place of abode and any country to which the Insured Person pays income taxes based upon employment in that country. In the event there is more than one Country of Residence under the above-listed criteria, the Country of Residence is the country meeting the above-listed criteria and listed by the Insured Person as their Country of Residence on the Application. For the purposes of this insurance, the Insured Person’s Country of Residence is not the Destination Country.

Custodial Care: Those types of Treatment, care or services, wherever furnished and by whatever name called, that are designed primarily to assist an individual in activities of daily life.

Declaration: The Declaration of Insurance issued by the Plan Administrator for and on behalf of the Company to the Insured Person contemporaneously with this Certificate evidencing the Insured Person’s insurance coverage under the Master Policy as evidenced by this Certificate.

Deductible: The dollar amount, as selected on the Application and specified in the Declaration, that the Insured Person must pay of ELIGIBLE MEDICAL EXPENSES per Injury or Illness prior to receiving benefits or coverage under this insurance, and not including any applicable Coinsurance.

Dental Provider; Dentist: A person duly licensed to practice dentistry in the state or country in which the dental service is rendered.

Dental Treatment: Treatment or supplies relating to the care, maintenance or repair of teeth, gums or bones supporting the teeth, including dentures and preparation for dentures.

Destination Country: All the geographical areas that the Insured Person is traveling to or within other than the primary place of residence declared on the Application. For the purposes of this insurance, the Destination Country is either the United States, Canada or Mexico.

Disabled: A person who has a congenital or acquired mental or physical defect that interferes with normal functioning of the body system or the ability to be self-sufficient.

Durable Medical Equipment (DME): Exclusively the following items: a standard basic hospital bed and/or a standard basic wheelchair.

Educational or Rehabilitative Care: Care for restoration (by education or training) of a person’s ability to function in a normal or near normal manner following an Illness or Injury. This type of care includes, but is not limited to job training, counseling, vocational or occupational therapy, and speech therapy.

Effective Date; Effective Date of Coverage: The later of (a) the date of coverage for the Insured Person as indicated on the Declaration or (b) the date that the Insured Person departs their Country of Residence.

Emergency: A medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person's life or limb in danger if medical attention is not provided within twenty-four (24) hours, based upon a reasonable medical certainty. Immediate medical intervention and attention is required as a result of a severe, life- threatening or potentially disabling condition.

Elective: Any Treatment or Surgery that is elected by the Insured Person, a Physician or a medical provider, that is scheduled in advance, is not urgent, and does not involve a medical Emergency.

Emergency Medical Evacuation: Emergency transportation from the Hospital or medical Facility where the Insured Person is located to a non-local Hospital or medical Facility following the recommendation by the attending Physician who certifies, to a reasonable medical certainty, that the Insured Person has experienced:

(a) a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person's life or limb in danger if medical attention is not provided within twenty-four (24) hours; and

(b) where Medically Necessary Treatment cannot be provided locally, either in the Facility of the attending Physician or another local Facility.

Emergency Treatment of Pregnancy: Initial Emergency Treatment of Pregnancy requiring Hospitalization in order to stabilize the Insured Person to prevent loss of life or limb. Emergency Treatment of Pregnancy does not include pre-natal, delivery, or post-natal Treatment or extended care.

Emergency Use Authorization (EUA): A temporary authorization issued by the U.S. Food and Drug Administration (FDA) to allow the use of unapproved medical product, service, a Surgery or Surgical Procedure, prescription medication, drug, biological product, Durable Medical Equipment (DME) or device; or by allowing an otherwise unapproved use or application of an approved medical product, service, Surgery or Surgical Procedure, prescription medication, drug, biological product, Durable Medical Equipment (DME) or device.

EST: United States Eastern Standard Time.

Experimental: Any Treatment that includes completely new, untested drugs, procedures, or services, or the use of which is for a purpose other than the use for which they have previously been approved by the U.S. Food and Drug Administration (FDA); new drug procedure or service combinations; and/or alternative therapies which are not generally accepted standards of current medical practice.

Extended Care Facility: An institution, or a distinct part of an institution, which is licensed as a Hospital, Extended Care Facility or rehabilitation Facility by the state or country in which it operates; and is regularly engaged in providing twenty- four (24) hour skilled nursing care under the regular supervision of a Physician and the direct supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation prescribed by a Physician; and provides each patient with active Treatment of an Illness or Injury. Extended Care Facility does not include a Facility primarily for rest, the aged, Substance Abuse, Custodial Care, nursing care, or for care of Mental or Nervous Disorders or the mentally incompetent.

Extreme Sports: Recreational activities involving a high degree of risk. These activities often involve speed, height, a high level of physical exertion, and/or highly specialized gear and often carry the potential risk of serious or permanent physical Injury and even death.

Facility: Licensed health care entity such as a Hospital, clinic, rehabilitation, and/or Extended Care Facility.

Family: An Insured Person, their Spouse, any Child or Children, and any Grandchild or Grandchildren who are covered as an Insured Person under this insurance plan.

Genetic Medicine: The study of the etiology, pathogenesis, and natural history of diseases and disorders that are fully or partially genetic in origin and the application of genetics to medicine or to medical practice, including the prevention, screening, diagnosis, surveillance, and Treatment of these diseases.

Governing Body or Authority: A nationally-recognized controlling organization for a sport or activity, or an organization that provides guidelines and recommendations in safety practices for a sport or activity.

Grandchild; Grandchildren: An Insured Person who is at least fourteen (14) days old but less than nineteen (19) years of age.

HIV: Human Immunodeficiency Virus, as that term is defined by the United States Centers of Disease Control.

HIV +: Laboratory evidence defined by the United States Centers for Disease Control as being positive for Human Immunodeficiency Virus infection.

Home Health Care Agency: A public or private agency or one of its subdivisions, which operates pursuant to law; and is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse; and maintains a daily record on each patient; and provides each patient with a planned program of observation and Treatment prescribed by a Physician.

Home Nursing Care: Services and/or Treatment provided by a Home Health Care Agency and supervised by a Registered Nurse that are directed toward the Convalescent care of a patient, provided always that such care is Medically Necessary and in lieu of Medically Necessary Inpatient care. Home Nursing Care does not include services or Treatment primarily for Custodial Care or rehabilitative purposes.

Hospice; Hospice Care: Care provided in an Inpatient Facility or at a patient’s home. Hospice Care must be certified by a Physician and life expectancy is six (6) months or less.

Hospital: An institution which operates as a Hospital pursuant to law; is licensed by the state or country in which it operates; operates primarily for the reception, care, and Treatment of sick or injured persons as Inpatient; provides twenty-four (24) hour nursing service by Registered Nurses on duty or call; has a staff of one (1) or more Physicians available at all times; provides organized Facilities and equipment for diagnosis and Treatment of acute medical or surgical conditions or Mental or Nervous Disorders on its premises; and is not primarily a long-term care Facility, Extended Care Facility, nursing, rest, Custodial Care, convalescent home, place for the aged, drug addicts or abusers, alcoholics or runaways, or similar establishment.

Hospitalization; Hospitalized: Confined and/or Treated in a Hospital as an Inpatient.

Illness: A sickness, disorder, illness, pathology, abnormality, malady, morbidity, affliction, disability, defect, handicap, deformity, birth defect, congenital defect, symptomatology, syndrome, malaise, infection, infirmity, ailment, disease of any kind, or any other medical, physical or health condition. Provided, however, that Illness does not include learning disabilities, or attitudinal disorders or disciplinary problems. All Illnesses that exist simultaneously or which arise subsequent to a prior Illness and which directly or indirectly relate to or result or arise from the same or related causes or as a consequence thereof or from one another are considered to be a single Illness. Further, if a subsequent Illness results or arises from causes or consequences that are the same as or related to the causes or consequences of a prior Illness, the subsequent Illness will be deemed to be a continuation of the prior Illness and not a separate Illness.

IMG Claim Form: A form which allows the Insured Person to request reimbursement or direct payment for medical services.

Implant: Any device, object, or medical item that is surgically imbedded, inserted, or installed for medical purposes within or on a patient’s body, including for orthotic or prosthetic reasons.

Initial Effective Date: The date the Insured Person originally obtains coverage under this insurance plan and maintains continuous unbroken coverage thereafter.

Injury: Bodily injury resulting or arising directly from an Accident. All Injuries resulting or arising from the same Accident shall be deemed to be a single Injury.

Inpatient: A person who has been admitted to and charged by a Hospital for bed occupancy for purposes of receiving Inpatient Hospital services. Generally, a patient is considered an Inpatient if billed by the Hospital for Charges as an Inpatient, and formally admitted as an Inpatient with the expectation that person will occupy a bed and (a) remain at least overnight or (b) is expected to need Hospital care for twenty-four (24) hours or more.

Insured Person: The person named as the Insured Person on the Declaration.

Intensive Care Unit: An area or unit of a Hospital that meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations for Special Care Units.

Interfacility Ambulance Transfer: Movement of the patient locally within the United States from one licensed health care Facility to another licensed health care Facility via air or land ambulance (examples: Hospital to Hospital, clinic to Hospital, Hospital to Extended Care Facility). The Interfacility Ambulance Transfer must be Medically Necessary and Pre-certified in advance to be an Eligible Medical Expense.

Investigational: Any Treatment that includes drugs, procedures, or services that are still in the clinical stages of evaluation and not yet approved for use by the U.S. Food and Drug Administration (FDA) including an Emergency Use Authorization by the FDA.

Local Ambulance Transport; Local Ambulance Expense: Transportation and accompanying Treatment provided by designated, licensed, qualified, professional emergency personnel from the location of an Accident, Injury or acute Illness to a Hospital or other appropriate health care Facility.

Master Policy: The applicable Master Policy issued by the Company to the Assured, and under which insurance coverage and benefits are provided by the Company to the Insured Person, subject to the Terms thereof, and as outlined and evidenced by this Certificate and subject to the Terms hereof. The Company, as insurance carrier and underwriter of the Master Policy, is solely liable and responsible for the coverage and benefits provided thereunder.

Maximum Limit: The cumulative total dollar amount of benefit payments and/or reimbursements available to an Insured Person under this insurance. When the Maximum Limit is reached, no further benefits, reimbursements or payments will be available under this insurance.

Medically Necessary; Medical Necessity: A Treatment, service, medicine or supply which is necessary and appropriate for the diagnosis or Treatment of an Illness or Injury based on generally accepted standards of current medical practice as determined by the Company. By way of example but not limitation, a service, Treatment, medicine or supply will not be considered Medically Necessary or a Medical Necessity if it is provided or obtained only as a convenience to the Insured Person or their provider; and/or if it is not necessary or appropriate for the Insured Person's Treatment, diagnosis or symptoms; and/or if it exceeds (in scope, duration or intensity) that level of care which is needed to provide safe, adequate, and appropriate diagnosis or Treatment.

Mental or Nervous Disorders: Any mental, nervous, or emotional Illness which generally denotes an Illness of the brain with predominant behavioral symptoms; an Illness of the mind or personality, evidenced by abnormal behavior; or an Illness or disorder of conduct evidenced by socially deviant behavior. Mental or Nervous Disorders include without limitation: psychosis; depression; schizophrenia; bipolar affective disorder; learning disabilities and attitudinal or disciplinary problems; any disease or condition, regardless of whether the cause is organic, that is classified as a Mental Disorder in the current edition of the International Classification of Diseases as published by the U.S. Department of Health and Human Services; and those psychiatric and other mental Illnesses listed in the current edition of the Diagnostic and Statistical Manual for Mental Disorders published by the American Psychiatric Association. For purposes of this insurance, Mental or Nervous Disorders does not include Substance Abuse.

Mortal Remains: The bodily remains or ashes of an Insured Person.

Natural Disaster: Widespread disruption of human lives by disasters such as flood, drought, tidal wave, fire, hurricane, earthquake, windstorm, or other storm, landslide, or other natural catastrophe or event resulting in migration of the human population for its safety. The occurrence must be a disaster that is due entirely to the forces of nature and could not reasonably have been prevented.

Newborn: An infant from the moment of birth through the first thirty-one (31) days of life.

Outpatient: A person who receives Medically Necessary Treatment by a Physician or other healthcare provider and is not an Inpatient, regardless of the hour that the person arrived at the Hospital, whether a bed was used, or whether the person remained in the Hospital past midnight.

Period of Coverage: The period beginning on the Effective Date of Coverage of this Certificate and ending on the earliest of the following dates:

(a) the termination date specified in the Declaration; or

(b) the termination date as determined in accordance with the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF COVERAGE FOR INSURED PERSONS provision.

The Period of Coverage can be no less than ninety (90) days and no more than twelve (12) consecutive months.

Physician: A duly educated, trained and licensed practitioner of the medical arts. A Physician must be currently and appropriately licensed by the state or country in which the services are provided, and the services must be within the scope of that license, training, experience, competence, and health professions standards of practice.

Plan Administrator: The Plan Administrator for this insurance is International Medical Group®, Inc., 9200 Keystone Crossing, Suite 800 Indianapolis, IN 46240, Telephone Number +1.317.655.4500, or +1.800.628.4664, Fax Number +1.317.655.4505, Website: http://www.imglobal.com, Email: insurance@imglobal.com. As the Plan Administrator, International Medical Group, Inc., acts solely as the disclosed and authorized agent and representative for and on behalf of the Company, and does not have, and shall not be deemed, considered or alleged to have any, direct, indirect, joint, several, separate, individual, or independent liability, responsibility or obligation of any kind under the Master Policy, the Declaration, any Riders or this Certificate to the Insured Person or to any other person or entity, including without limitation to any Physician, Hospital, Extended Care Facility, Home Health Care Agency, or any other health care or medical service provider or supplier.

Pre-certification; Pre-certify: A general determination of Medical Necessity only, made by the Company in reliance and based upon the completeness and accuracy of the information provided by the Insured Person and/or the Insured Person’s healthcare or medical service providers, guardians, Relatives and/or proxies at the time thereof. Pre-certification is not an assurance, authorization, pre-authorization or verification of coverage, a verification of benefits, or a guarantee of payment.

Pre-existing Condition: An Illness, disease, or other condition of the Insured Person that in the twelve (12) month period before the Insured Person’s coverage became effective under this insurance: a) first manifested itself, worsened, became acute, or exhibited symptoms that would have caused a person to seek diagnosis, care, or Treatment; or b) required taking prescribed drugs or medicines, unless the condition for which the prescribed drug or medicine is taken remains controlled without any change in the required prescription; or c) was Treated by a Physician or Treatment had been recommended by a Physician.

Pregnancy; Pregnant: The process of growth and development within a woman’s reproductive organs of a new individual from the time of conception through the phases where the embryo grows and fetus develops to birth.

Premium: The Premium payments required to effectuate and maintain the Insured Person’s insurance coverage and benefits under this insurance, in the amounts and at the times (“Due Dates”) established by the Company in its sole discretion from time to time.

Professional Athletics: A sport activity, including practice, preparation, and actual sporting events, for any individual or organized team that is a member of a recognized professional sports organization; is directly supported or sponsored by a professional team or professional sports organization; is a member of a playing league that is directly supported or sponsored by a professional team or professional sports organization; or has any athlete receiving for their participation any kind of payment or compensation, directly or indirectly, from a professional team or professional sports organization.

Proof of Claim: Duly completed and signed claim form, authorization to release medical information, Physician, Hospital and other healthcare provider’s statement detailing the cost and services rendered and proof of payment for services rendered. Refer to the PROOF OF CLAIM provision for further details.

Radiology: Specialty services that use medical imaging to diagnose and Treat an Illness or Injury seen within the body. Imaging techniques used in Radiology include x-ray, radiography, ultrasound, computed tomography (CT), nuclear medicine, including positron emission tomography (PET), and magnetic resonance imaging (MRI).

Registered Nurse: A graduate nurse who has been registered or licensed to practice by a State Board of Nurse Examiners or other state authority, and who is legally entitled to place the letters "R.N." after their name.

Relative: A parent, legal guardian, Spouse, son, daughter, Grandchild, or immediate Family member of the Insured Person.

Rider: Any exhibit, schedule, attachment, amendment, endorsement, Rider or other document attached to, issued in connection with, or otherwise expressly made a part of or applicable to, the Master Policy, this Certificate, the Declaration, or the Application, as the case may be.

Routine Physical Examination: Examination of the physical body by a Physician for preventative or informative purposes only, and not for the Treatment of any previously manifested, symptomatic, diagnosed or known Illness or Injury.

Self-inflicted: Action or inaction by the Insured Person that the Insured Person consciously understands will or may cause or contribute, directly or indirectly, to their personal Injury or Illness. Self-inflicted specifically includes failure of an Insured Person to follow their doctor’s orders, complete prescriptions as directed, or follow any health care protocol or procedures designed to return or maintain their health.

Spouse: An Insured Person’s legal Spouse or domestic partner. Such relationship must have met all requirements of a valid marriage contract, domestic partnership, or civil union in the state or Country of Residence where the parties’ ceremony was performed.

Stacked Insurance: Purchasing the same or like insurance product through the Company, for the same area of coverage, for the same or similar coverage period, and for the same coverage intent to increase a claims payout.

Substance Abuse: Alcohol, drug or chemical abuse, misuse, illegal use, overuse or dependency.

Superbill: An itemized list of all services provided to the Insured Person by a Physician or medical provider.

Surgery; Surgical Procedure: An invasive diagnostic or surgical procedure, or the Treatment of Illness or Injury by manual or instrumental operations performed by a Physician while the patient is under general or local anesthesia.

Teladoc Consultation: A phone or video consultation provided by TELADOC HEALTH INTERNATIONAL, S.A.U., a Teladoc Health Group company, incorporated in Spain, a network of board-certified providers available on-demand twenty-four (24 hours) a day, seven (7) days a week, three hundred sixty-five (365) days a year to diagnose, treat and prescribe medication (when necessary) for non-emergency medical issues. Teladoc does not replace existing primary care Physician relationships but supplements them

Teleconsultation: Treatment of an Illness or Injury involving the Insured Person and a Physician at different locations, and who are connected by video, audio and computers.

Telehealth: The distribution of health-related services and information via electronic information and telecommunication technologies. It allows long-distance patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions.

Telemedicine: A process where an Insured Person is teleconferenced for a Teleconsultation with a qualified Physician but is attended at the remote point by a Telepresenter. This Telepresenter may be equipped with either an exam camera or a stethoscope, and possibly other medical equipment as well, for the purpose of using those medical devices to gather and relay data to the Physician’s office or to the Treating Physician.

Telepresenter: A medical assistant who is present with the Insured Person during a Teleconsultation led by a remote Physician.

Terms: All Terms, provisions, conditions, definitions, Deductibles, Coinsurance, limits, sub-limits, limitations, wordings, restrictions, requirements, qualifications and/or exclusions that bind the Insured Person as set forth in the Master Policy, Application and any Riders.

Terrorism: Criminal acts, including against civilians, committed with the intent to cause death or serious bodily injury, or taking of hostages, with the purpose to provide a state of terror in the general public or in a group of persons or particular persons, intimidate a population, or compel a government or international organization to do or to abstain from doing an act.

Traumatic Dental Injury: An injury that includes:

(a) Trauma involving the face, skull, neck and/or jaws which resulted in loss of teeth or a serious dental Injury; and

(b) Injury requiring evaluation and Treatment in a Hospital Emergency room or a Hospital confinement setting.

Travel Warning; Emergency Travel Advisory: Published statement or website document issued by the United States Department of State, Bureau of Consular Affairs, Centers for Disease Control and Prevention, United Nations, World Health Organization, or similar government or non-governmental agency warning that travel to specific identified countries, regions or locations poses serious risks to safety and security or exposes the Insured Person to a greater likelihood of life- threatening risks, including but not limited to United States Department of State Travel Advisories levels "3 - Reconsider travel" and "4 - Do not travel."

Treated; Treating; Treatment: Any and all services and procedures rendered in the management and/or care of a patient for the purpose of identifying, diagnosing, treating, curing, preventing, controlling and/or combating any Illness or Injury, including without limitation: verbal or written advice, consultation, examination, discussion, diagnostic testing or evaluation of any kind, pharmacotherapy or other medication, and/or Surgery.

Treating Physician: A Physician providing Treatment to an Insured Person.

Unexpected: Sudden, unintentional, not expected and unforeseen.

Universal Billing Form: UB 04 and CMS 1500 forms, which are standard and uniform forms in the healthcare industry to submit insurance claims to Medicare or other health insurance companies for reimbursement.

Urgent Care Clinic: A standalone Facility or a Facility located inside a Hospital that staffs Physicians, nurse practitioners (NP) or physician assistants (PA). Urgent Care Clinics provide medical services that are not life-threatening Injuries or Illnesses. Urgent Care Facilities have onsite x-ray equipment and provide Treatment for more severe urgent care services such as broken bones, burns and other non-emergent conditions that Walk-in Clinics are unable to treat.

Usual, Reasonable and Customary: A typical and reasonable amount of reimbursement for similar services, medicines, or supplies within the area in which the Charge is incurred. In determining the typical and reasonable amount of reimbursement, the Company may, in its reasonable discretion, consider one or more of the following factors, without limitation: the amount charged by the provider; the amount charged by similar providers or providers in the same or similar locality; the amount reimbursed by other payors for the same or comparable services, medicines or supplies in the same or similar locality; whether the services or supplies were unbundled or should have been included in the allowance of another service; the amount reimbursed by other payors for the same or comparable services, medicines or supplies in other parts of the country; the cost to the provider of providing the service, medicine or supply; the level of skill, extent of training, and experience required to perform the procedure or service; the length of time required to perform the procedure or service as compared to the length of time required to perform other similar services; the length of time required to perform the procedure or service as compared to national standards and/or benchmarks; the severity or nature of the Illness or Injury being Treated; and such other factors as the Company, in the reasonable exercise of its discretion, determines are appropriate.

Virtual Physician Visit: A live consultation conducted over the internet or phone between Physician and the Insured Person.

Walk-in Clinic: A medical Facility that provides medical services for a minor Injury or Illness. The clinics are often found in or near retail establishments or pharmacies. The staff providing medical services are nurse practitioners and physician assistants.

Worsening: Deterioration of an Insured Person’s medical condition, symptoms or diagnosis that may lead to further complications following a Discharge Against Medical Advice or an increased likelihood or need for readmission.

CLAIMS NOTIFICATION: All claims and related claim information should be filed with the Company through the Plan Administrator via the MyIMG customer portal at www.imglobal.com/member within the timely filing requirements outlined below. Alternatively, claims can be filed at the contact information below:
International Medical Group Attn: Claims Department PO Box 240429
Apple Valley, MN 55124 USA

Proof of Claim: When the Insured Person receives Treatment or the Company receives notice of a claim for benefits under this insurance, the Insured Person shall submit an International Medical Group (IMG) Claim Form as a necessary component of the Proof of Claim. An IMG Claim Form may be completed online via the MyIMG customer portal at www.imglobal.com/member or obtained by contacting the Company.
(a)    A Proof of Claim shall not be effective and will not satisfy the Terms of this insurance unless it includes all the following:
(i)    a duly completed, timely submitted and signed IMG Claim Form for each new Illness, diagnosis or Injury unless the Company waives such requirement in writing
(ii)    an Authorization for Release of Medical Information when specifically requested by IMG
(iii)    all original Universal Billing Forms, Superbill and statements of service rendered from Physicians, Hospitals, and other healthcare or medical service providers involved with respect to the claim
(iv)    all original receipts for any costs, prescription medications, fees or expenses that have been incurred or paid by, or on behalf of, the Insured Person with respect to the claims, including without limitation all original receipts for any cash and/or credit card payments. The provider of service’s full name, address, telephone number (including area/country code), date of service, description of service (applicable procedure codes), and diagnosis codes must be included on the receipts.
(v)    If the claims are submitted electronically, copies of the above items are acceptable; however, the Company reserves the right to request the original documents.
(b)    TIMELY FILING REQUIREMENTS: The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have one hundred eighty (180) days from the date a claim is incurred to submit a complete Proof of Claim. The Company at its option may pend resolution and adjudication of submitted claims and/or may deny coverage due to any of the following:
(i)    IMG’s receipt of an incomplete Proof of Claim
(ii)    failure to submit any Proof of Claim
(iii)    Insured Person’s, Physician’s or Hospital’s failure to submit a timely Proof of Claim
(c)    The Company may require the Insured Person to sign an Authorization for Release of Medical Information to request medical records on their behalf or supply the Company with additional documentation if the Company is unable to make a benefit determination based on the submitted Proof of Claim. The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have sixty (60) days from the date of the request to submit the requested information. If the information is not received within the designated time period, previously submitted and subsequent claims will be denied.

APPEALING A CLAIM: In the event the Company denies all or part of a claim, the Insured Person shall have ninety (90) days from the date that the notice of denial was mailed to the Insured Person’s last known residence or mailing address within which to appeal the determination. The Insured Person must file an appeal prior to bringing any legal action under the contract of insurance. The Insured Person should submit a written request for an appeal along with comments, all relevant, pertinent or related documents, medical records and other information relating to the claim.
The appeal must be sent to:
International Medical Group Attn: Benefit Review
PO Box 240429
Apple Valley, MN 55124 USA
The Company’s review will take into account all comments, documents, records and other information submitted by the Insured Person relating to the claim without regard to whether such information was submitted or considered in the initial claim determination. Upon receipt of a written appeal, the Company shall have an opportunity for further reasonable investigation and/or review as set forth in the CONDITIONS AND GENERAL PROVISIONS, EXPLANATION OR VERIFICATION OF BENEFITS provision and will respond in writing as soon as reasonably practicable, and in any event within ninety (90) days from receipt thereof.

CLAIM SETTLEMENT: Eligible and covered claims for Eligible Medical Expenses or other benefits under this insurance that have previously been paid by or on behalf of the Insured Person at the time of the Company’s favorable adjudication thereof will be reimbursed by the Company directly to the Insured Person, by check, at their last known residence or mailing address. While this insurance is in effect, in order to effectuate proper administration, the Insured Person shall undertake to promptly notify the Company of any change in such addresses. Eligible and covered claims for Eligible Medical Expenses or other benefits under this insurance that have not been paid by or on behalf of the Insured Person at the time of adjudication will be paid by the Company by check or electronic funds transfer to the Insured Person at their last known residence or mailing address, or, at the sole option and discretion of the Company (but without obligation to do so), and as an accommodation to the Insured Person, directly to the provider(s), as applicable. All claim settlements, payments and reimbursements are subject to the insurance plan shown in the Declaration and all other Terms of this insurance. No healthcare or medical service provider or supplier, or any other third-party, shall have any direct or indirect interest, claim or right of action against the Company under this Certificate, the Declaration or the Master Policy, whether by purported assignment of benefits, subrogation of interests or otherwise, unless first expressly agreed and consented to in writing by the Company, and notwithstanding the Company’s exercise or failure to exercise any option or discretion under this provision regarding the method of claim payment. No such provider, supplier or other third-party is intended to have or shall have any rights as a third-party beneficiary under this Certificate, the Declaration, or the Master Policy.

FRAUDULENT CLAIMS: A person who knowingly and with intent to defraud the Company files a statement of claim containing any false, incomplete, or misleading information commits a felony. If any claim or request for benefits under this insurance shall knowingly be in any respect false, incomplete, misleading, concealing, fraudulent or deceitful or if the Insured Person or anyone acting for or on their behalf under this insurance knowingly uses any false, incomplete, misleading, concealing, fraudulent or deceitful statements regarding the Insured Person, the insurance contract and all coverage thereunder may be cancelled, voided, rescinded and terminated by the Company in its sole and absolute discretion, and the Company shall have no obligation or liability for any such benefits, coverage or claims.

PRE-CERTIFICATION REQUIREMENTS: Pre-certification is a general determination of Medical Necessity only, and all such determinations are made by the Company (acting through its authorized agents and representatives) in reliance and based upon the completeness and accuracy of the information provided by the Insured Person and/or their Relatives, guardians and/or healthcare providers at the time of Pre-certification. The Company reserves the right to challenge, dispute and/or revoke a prior determination of Medical Necessity based upon subsequent information obtained. Pre-certification is not an assurance, authorization, preauthorization, or verification of Treatment or coverage, a verification of benefits, or a guarantee of payment. The fact that Treatment or supplies are Pre-certified by the Company does not guarantee the payment of benefits, the availability of coverage, or the amount of or eligibility for benefits. The Company’s consideration and determination of a Pre-certification request, as well as any subsequent review or adjudication of all medical claims submitted in connection therewith, shall remain subject to all of the Terms of this insurance, including exclusions for Pre- existing Conditions and other designated exclusions, benefit limitations and sub-limitations, and the requirement that claims be Usual, Reasonable and Customary. Any consideration or determination of a Pre-certification request shall not be deemed or considered as the Company’s approval, authorization or ratification of, recommendation for, or consent to any diagnosis or proposed course of Treatment. Neither the Company nor the Plan Administrator (nor anyone acting on their respective behalves) has any authority or obligation to select Physicians, Hospitals, or other healthcare providers for the Insured Person, or to make any diagnosis or medical Treatment decisions on behalf of the Insured Person, and all such decisions must be made solely and exclusively by the Insured Person and/or their family members or guardians, Treating Physicians and other healthcare providers. If the Insured Person and their healthcare providers comply with the Pre- certification requirements of the Master Policy and this Certificate, and the Treatment or supplies are Pre-certified as Medically Necessary, the Company will reimburse the Insured Person for Eligible Medical Expenses up to the amount shown in the BENEFIT SUMMARY incurred in relation thereto, subject to all Terms of this insurance. Eligibility for and payment of benefits are subject to all of the Terms of this insurance.

Precertification
Each proposed hospital admission, inpatient or outpatient surgery, and other procedures as noted in the Certificate Wording must be precertified for medical necessity. It is important to note that precertification is only a determination of medical necessity, not an assurance of coverage, verification of benefits or a guarantee of payment. All medical expenses must meet usual, reasonable, customary, and eligible payment guidelines. Please refer to the Certificate Wording for full details of the precertification requirements.
Online Precertification link: https://www.imglobal.com/member/precertification 

SPECIFIC REQUIREMENTS: The following must always be Pre-certified for Medical Necessity by the Company through the Plan Administrator before admission or receiving the Treatments and/or supplies:
(d)    Extended Care Facility
(e)    Home Nursing Care
(f)    Inpatient Hospitalization
(g)    Interfacility Ambulance Transfer
(h)    Surgery or Surgical procedure.

GENERAL REQUIREMENTS: To comply with the Pre-certification requirements of this insurance for the Treatments and/or supplies or services listed in the SPECIFIC REQUIREMENTS provision, above, the Insured Person or their Physician or healthcare provider must perform all of the following:
(i)    contact the Company through the Plan Administrator at the contact information below and on the Insured Person’s ID card as soon as possible and before the Treatment or supply is to be obtained.
Inside the United States: +1.800.628.4664
Outside the United States: +1.317.655.4500 (Collect if necessary) E-mail: precertification@imglobal.com
Website: www.imglobal.com/member/precertification
(j)    comply with the instructions of the Company and submit any information or documents required by the Company
(k)    notify all Physicians, Hospitals and other healthcare providers that this insurance contains Pre-certification requirements and ask them to fully cooperate with the Company.

LOSS OF COVERAGE / BENEFITS FOR NON-COMPLIANCE OF PRE-CERTIFICATION REQUIREMENTS:  If the
Insured Person or their healthcare providers do not comply with the Pre-certification requirements for the Treatment or supplies identified in the SPECIFIC REQUIREMENTS subparagraphs above, or if such Treatment or supplies are not Pre- certified:
(l)    Eligible Medical Expenses incurred with respect to said Treatment and/or supplies will be reduced by the amount shown in the BENEFIT SUMMARY
(m)    the Deductible will be subtracted from the remaining amount
(n)    Coinsurance will be applied.

EMERGENCY PRE-CERTIFICATION: In the event of an Emergency Hospital admission, Pre-certification must be completed within forty-eight (48) hours after the admission, or as soon as is reasonably possible.

CONCURRENT REVIEW: For Inpatient Treatment of any kind, the Company will Pre-certify a limited number of days of confinement based upon the disclosed medical condition. Thereafter, Pre-certification must again be requested and approved if additional days of Inpatient Treatment are necessary.

APPEAL PROCESS: If the Insured Person disagrees with a Pre-certification decision of the Company, the Insured Person may in writing ask the Company to reconsider the decision and may supply additional documentation to support the appeal. The Company may reconsider its decision based on review of the additional documentation and facts, if any. The Company will advise the Insured Person of its decision within a reasonable time frame following receipt of additional documentation and facts.
The appeal must be sent to:
Phone: +1.317.655.4500, Option #2
Fax: +1.317.833.1990: ATTN: Pre-certification–- Appeals Email: precertification@imglobal.com

DEFINITIONS
Proof of Claim: Duly completed and signed claim form, authorization to release medical information, Physician, Hospital and other healthcare provider’s statement detailing the cost and services rendered and proof of payment for services rendered. Refer to the PROOF OF CLAIM provision for further details.

Pre-certification; Pre-certify: A general determination of Medical Necessity only, made by the Company in reliance and based upon the completeness and accuracy of the information provided by the Insured Person and/or the Insured Person’s healthcare or medical service providers, guardians, Relatives and/or proxies at the time thereof. Pre-certification is not an assurance, authorization, pre-authorization or verification of coverage, a verification of benefits, or a guarantee of payment