U.S. Citizens and Non-U.S. Citizens who are at least 14 days of age are eligible for coverage outside of their home countries, except as provided under home country coverage. U.S. Citizens and residents are not eligible for coverage within the U.S, except as provided under home country coverage or an eligible benefit period. Individuals age 70 to 79 as of the certificate effective date are subject to a $100,000 overall maximum limit or less. Individuals age 80 and over as of the certificate effective date are subject to a $10,000 overall maximum limit.

Schedule of Benefits and Limits

Plan Details

 

Overall Maximum Limit

Age 80 or older: $10,000.

Age 65 to 79: $50,000 or $100,000

All others: $50,000, $100,000, $250,000, $500,000, $1,000,000 or $2,000,000

Maximum per Injury / Illness

Age 80 or older: $10,000.

Age 65 to 79: $50,000 or $100,000

All others: $50,000, $100,000, $250,000, $500,000, $1,000,000, or $2,000,000

Deductibles

$0, $100, $250, $500, $1,000, $2,500, or $5,000 per certificate period

Coinsurance

We will pay 100% of eligible expenses, after the deductible, to the overall maximum limit

BenefitLimit
Hospital Room and Board Average semi-private room rate, including nursing services
Intensive Care Unit Up to the overall maximum limit
Local Ambulance Usual, reasonable and customary charges, when covered illness or injury results in hospitalization as inpatient.
Emergency Room Co-payment Claims incurred in U.S.
You shall be responsible for a $200 co-payment for each use of emergency room for an illness unless you are admitted to the hospital. There will be no co-payment for emergency room treatment of an injury.

Claims incurred outside the U.S.
No co-payment
Urgent Care Center Co-payment Claims incurred in U.S.
For each visit, you shall be responsible for a $15 co-payment.
– Co-payment is waived for members with a $0 deductible.
– not subject to deductible

Claims incurred outside the U.S.
No co-payment
Outpatient Physical Therapy and Chiropractic Care Up to $50 maximum per day. Must be ordered in advance by a physician.
Emergency Dental (Acute Onset of Pain) Up to $300 - not subject to deductible
Emergency Eye Exam for a Covered Loss Up to $150. $50 deductible per occurrence (plan deductible is waived).
Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions) (only available to members under age 80) Up to the overall maximum limit
Up to $25,000 lifetime maximum for Emergency Medical Evacuation
Terrorism Up to $50,000 lifetime maximum, eligible medical expenses only
All Other Eligible Medical Expenses Up to the overall maximum limit
Emergency Travel BenefitsLimit
Emergency Medical Evacuation Up to $1,000,000 lifetime maximum, except as provided under Acute Onset of Pre-existing Condition
- not subject to deductible or overall maximum limit
Repatriation of Remains Equal to the elected overall maximum limit - not subject to deductible or coinsurance. This limit is for this benefit only and is not included in or subject to the overall maximum limit.
Local Burial or Cremation Up to $5,000 lifetime maximum - not subject to deductible
Crisis Response - Ransom, Personal Belongings, and Crisis Response Fees and Expenses Up to $10,000 - not subject to deductible or overall maximum limit
Optional Crisis Response Rider with Natural Disaster Evacuation Up to $90,000 per certificate period, with $10,000 maximum for Natural Disaster Evacuation
- not subject to deductible or overall maximum limit
Emergency Reunion Up to $100,000, subject to a maximum of 15 days - not subject to deductible
Bedside Visit Up to $1,500 - not subject to deductible
Return of Minor Children Up to $50,000 - not subject to deductible
Pet Return Up to $1,000 - not subject to deductible
Political Evacuation Up to $100,000 lifetime maximum
- not subject to deductible
Trip Interruption Up to $10,000 - not subject to deductible
Common Carrier Accidental Death
Ages 18 through 69
Under age 18
Ages 70 through 74
Ages 75 and older

$50,000
$10,000
$25,000
$12,500

Subject to a maximum of $250,000 any one family or group.
- not subject to deductible or overall maximum limit
Accidental Death & Dismemberment (excludes loss due to Common Carrier Accident)  
Ages 18 through 69 Lifetime Maximum - $25,000
Death - $25,000
Loss of 2 Limbs - $25,000
Loss of 1 Limb - $12,500
Under age 18 Lifetime Maximum - $5,000
Death - $5,000
Loss of 2 Limbs - $5,000
Loss of 1 Limb - $2,500
Ages 70 through 74 Lifetime Maximum - $12,500
Death - $12,500
Loss of 2 Limbs - $12,500
Loss of 1 Limb - $6,250
Ages 75 and older Lifetime Maximum - $6,250
Death - $6,250
Loss of 2 Limbs - $6,250
Loss of 1 Limb - $3,125

$250,000 maximum benefit any one family or group.
- not subject to deductible or overall maximum limit
Optional Accidental Death & Dismemberment Rider (only available to members age 18 through age 69) Lifetime Maximum - $25,000 Death - $25,000
Loss of 2 Limbs - $25,000
Loss of 1 Limb - $12,500
- not subject to deductible or overall maximum limit
Lost Checked Luggage Up to $1,000 - not subject to deductible
Travel Delay Up to $100 a day after a 12-hour delay period requiring an unplanned overnight stay. Subject to a maximum of 2 days. - not subject to deductible
Lost or Stolen Passport/Travel Visa Up to $100 - not subject to deductible
Border Entry Protection Up to $500 if traveling on a valid B-2 visa and denied entrance at the U.S. border. - not subject to deductible
Natural Disaster - Replacement Accommodations Up to $250 a day for 5 days - not subject to deductible
Hospital Indemnity $100 per day of inpatient hospitalization - not subject to deductible
Personal Liability Up to:
$25,000 lifetime maximum
$25,000 third person injury
$25,000 third person property
$2,500 related third person property
- not subject to deductible or overall maximum limit
Optional Personal Liability Rider Up to $75,000 lifetime maximum - not subject to deductible or overall maximum limit

Certificate Period means the period of time beginning on the date and time of the certificate effective date and ending on the date and time of the certificate termination date.

Coinsurance means your payment of eligible expenses as specified in the Schedule of Benefits and Limits.

Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and Limits that you must pay per certificate period before eligible expenses are paid.

Usual, Reasonable and Customary means the lesser of the following:

  1. One and a half times (150%) of the charges payable under the United States Medicare program, for claims incurred outside the PPO network within the U.S., or
  2. Most common charge for similar services, medicines or supplies within the area in which the charge is incurred, so long as those charges are reasonable. What is defined as usual, reasonable and customary charges will be determined by us. In determining whether a charge is usual, reasonable and customary, we may consider one or more of the following factors: 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 services as compared to the length of time required to perform other similar services; the severity or nature of the illness or injury being treated; the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged 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; such other factors we, in the reasonable exercise of discretion, determine are appropriate.

 

Article 11 - Eligible Expenses

Subject to the limits set forth in the Schedule of Benefits and Limits, and subject to the conditions and restrictions contained in this provision, we will pay the following expenses incurred while this insurance is in effect.

Medical & Repatriation Expenses

Medical Expenses

YOU ARE COVERED:

1. Charges made by a hospital for:

a. Daily room and board and nursing services not to exceed the average semi-private room rate; and

b. Daily room and board and nursing services in Intensive Care Unit; and

c. Use of operating, treatment or recovery room; and

d. Services and supplies which are routinely provided by the hospital to persons for use while inpatients; and

e. Emergency treatment of an injury, even if hospital confinement is not required; and

f. Emergency treatment of an illness; subject to emergency room co-pay as outlined in the Schedule of Benefits and Limits. ER co-payment is waived when you are directly admitted to the hospital as inpatient for further treatment of that illness.

2. Surgery at an outpatient surgical facility, including services and supplies.

3. Charges made by a physician for professional services, including surgery. Charges for an assistant surgeon are covered up to 20% of the usual, reasonable and customary charge of the primary surgeon, but standby availability will not be deemed to be a professional service and therefore is not covered hereunder.

4. Dressings, sutures, casts or other supplies which are medically necessary and administered by or under the supervision of a physician, but excluding nebulizers, oxygen tanks, diabetic supplies, other supplies for use or application at home, and all devices or supplies for repeat use at home, except durable medical equipment.

5. Diagnostic testing using radiology, ultrasonographic or laboratory services (psychometric, intelligence, behavioral and educational testing are not included).

6. Artificial limbs, eyes or larynx, breast prosthesis or basic functional artificial limbs, but not the replacement or repair thereof.

7. Reconstructive surgery when the surgery is directly related to surgery which is covered hereunder.

8. Hemodialysis and the charges by the hospital for processing and administration of blood or blood components but not the cost of the actual blood or blood components

9. Oxygen and other gasses and their administration by or under the supervision of a physician.

10. Anesthetics and their administration by a physician.

11. Drugs which require prescription by a physician for treatment of a covered injury or illness, but not for the replacement of lost, stolen, damaged, expired or otherwise compromised drugs, and for a maximum supply of 60 days per prescription.

12. Care in a licensed extended care facility upon direct transfer from an acute care hospital.

13. 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 and only in lieu of medically necessary inpatient hospitalization.

14. Emergency local ambulance transport necessarily incurred in connection with injury or illness resulting in inpatient hospitalization.

15. Emergency dental treatment and dental surgery necessary to restore or replace sound natural teeth lost or damaged in an accident which was covered under this insurance.

16. Emergency dental treatment necessary to resolve acute onset of pain, provided treatment is obtained within 24 hours of the acute onset of pain.

17. Emergency Eye Exam if your prescription corrective lenses are lost or damaged due to a covered loss and an exam is required to obtain a lens prescription for medically necessary correction lenses, but not for the replacement cost of prescription corrective lenses or contact lenses.

18. Medically necessary rental of durable medical equipment (consisting of a standard basic hospital bed and or a standard basic wheelchair) up to the purchase prices.

19. Outpatient physical therapy or chiropractic care if prescribed by a physician who is not affiliated with the physical therapy or chiropractic practice, necessarily incurred to continue recovery from a covered injury or illness.

20. Injury or illness resulting from participation in sports or athletic activities not otherwise excluded under this insurance.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

Emergency Medical Evacuation

YOU ARE COVERED:

1. Emergency air transportation to a suitable airport nearest to the hospital where you will receive treatment; and

2. Emergency ground transportation necessarily preceding emergency air transportation; and from the destination airport to the hospital where you will receive treatment.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The evacuation is recommended by the attending physician who certifies that it is medically necessary and that transportation by any other method would result in the loss of your life or limb; and

2. The evacuation is agreed upon by you or your relative; and

3. Travel arrangements, excluding Emergency Local Ambulance, are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. The illness or injury giving rise to the expense is not covered under this insurance; or

2. Medically necessary treatment, services and supplies can be provided locally; or

3. If transportation by any other method would not result in the loss of your life or limb; or

4. The condition giving rise to the Emergency Medical Evacuation did not occur spontaneously and without advance warning, either in the form of physician recommendation or symptoms which would have caused a prudent person to seek medical attention prior to the onset of the emergency; or

5. Expenses are directly or indirectly from anything in the General Exclusions.

We will provide Emergency Medical Evacuation only to the nearest hospital that is qualified to provide the medically necessary treatment, services and supplies to prevent your loss of life or limb.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

Notwithstanding the foregoing, and if you are visiting the U.S., we will pay for expenses to return you to your home country if the attending physician and our medical consultant agree that transfer to your home country is more appropriate than transfer to the nearest qualified hospital.

Trip Interruption

YOU ARE COVERED:

1. The cost of an economy one-way air or ground transportation ticket for you to the terminal serving the area of your principal residence, and/or

2. The cost of an economy one-way air and/or ground transportation ticket for you from the area where you were hospitalized following an Emergency Medical Evacuation to the area where you were initially evacuated from or to the terminal serving the area of your principal residence.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You provide proof of one or more of the following events: destruction, after departure from home country, resulting from fire or weather of more than 40% of your principal residence, or death of a parent, spouse, sibling, child, or grandchild; or

2. Following a covered Emergency Medical Evacuation, the attending physician states that it is medically necessary for you to return to your home country or to the area from which you were initially evacuated for continued treatment, recuperation and recovery.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

Return of Minor Children

YOU ARE COVERED:

1. The cost of a one-way economy air and/or ground transportation ticket for each covered minor child to the terminal serving the area of the principle residence of each minor child.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You are the only person age 18 or older, traveling with one or more minor children under the age of 18 who are also covered hereunder; and

2. You are hospitalized for treatment of a covered illness or injury, resulting in the children being left unattended for a period of time expected to exceed 36 hours; and

3. The Return of Minor Children benefit must be agreed upon by you and/or by an authorized adult relative of the affected, covered minor children.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

POLITICAL EVACUATION

YOU ARE COVERED: 1. The cost of transportation by the most economical means possible for you to the nearest country of safety or to your home country. We will determine to which country you will be evacuated.

YOU ARE NOT COVERED unless you fulfill the following conditions: 1. The U.S. Department of State has issued a level 3 or level 4 travel advisory after your arrival in the destination country; and 2. Your coverage was effective prior to the advisory being issued; and 3. You contact us within 10 days of the date the travel advisory is issued.

YOU ARE NOT COVERED IF: 1. Expenses arise directly or indirectly from anything in the General Exclusions

 

Repatriation of Remains

YOU ARE COVERED:

1. Air or ground transportation of bodily remains or ashes to the airport or ground transportation terminal nearest your principal residence; and

2. Reasonable costs of preparation of the remains necessary for transportation

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The illness or injury giving rise to the expense are covered under this insurance; and 

2. Travel arrangements are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

We are held harmless and shall not be held liable for loss of or any damage or other impairment to bodily remains incurred during the repatriation process or otherwise.

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

Local Burial or Cremation

YOU ARE COVERED:

1. For you to be buried or cremated in the country of death in lieu of Repatriation of Remains up to the specified benefit maximum.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The illness or injury giving rise to the expense is covered under this insurance; and

2. Travel arrangements are approved in advance and coordinated by us.

YOU ARE NOT COVERED IF:

1. The death occurs in your home country; or

2. The Emergency Medical Evacuation or Repatriation of Remains benefit is used; or

3. Expenses arise directly or indirectly from anything in the General Exclusions. 

The timeliness of arrangements can be affected by circumstances which are not within our control such as: availability of transportation equipment and staff, delays or restrictions on flights caused by mechanical problems, government officials, telecommunications problems, weather and other acts of God. We shall not be held liable for any delays that are not within our direct and immediate control.

Indemnity Benefit & Visitation Expenses 

Hospital Indemnity

YOU ARE COVERED:

1. The Hospital Indemnity benefit for each night you spend in the hospital. 1. You must provide verification of an eligible inpatient hospitalization.

 YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You must provide verification of an eligible inpatient hospitalization

 YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

Emergency Reunion

YOU ARE COVERED:

1. The cost of an economy round-trip air or ground transportation ticket for one relative for transportation to the terminal serving the area where you are hospitalized or are to be hospitalized following Emergency Medical Evacuation; and

2. Reasonable expenses for lodging and meals for the relative, which are incurred in the area where you are hospitalized for a period not to exceed 15 days.

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You have a covered Emergency Medical Evacuation.

 

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

 

 

Bedside Visit

YOU ARE COVERED:

1. The cost of an economy round-trip air or ground transportation ticket for one relative for transportation to the terminal serving the area where you are hospitalized or are to be hospitalized.

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You are confined to a hospital intensive care unit following a covered life-threatening bodily injury or life-threatening illness.

 

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

 

Travel Assistance

Travel Delay:

 

YOU ARE COVERED

1. Reimbursement for reasonable accommodations and meals when your delay requires an unplanned overnight stay.

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

 

1. The delay must be twelve (12) hours or more and certified due to the following reasons:

a. Delay of common carrier (which is certified by the common carrier); or

b. A traffic accident while en route to the point of departure from an airport outside of your home country (substantiated by a police report); or

c. Organized labor strike, or you being hijacked or quarantined; or

d. Stolen passports or travel documents (substantiated by a police report).

 

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

 

Common Carrier means an airplane, bus, train or watercraft operating for commercial purposes and carrying fare-paying passengers on regularly scheduled and published routes.

 

 

 

 

Lost Checked Luggage

 

YOU ARE COVERED:

1. Replacement of clothes and personal hygiene items, not to exceed $50 any one item.

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

 

1. The lost checked luggage must have been checked, in accordance with routine luggage checking procedures, for transportation with you, on board a regularly scheduled commercial airline or cruise line, upon which you were a fare-paying passenger; and

 

2. You must file a formal claim for lost luggage with the transportation provider, and follow all instructions and take all measures as directed by the transportation provider to locate and retrieve the lost checked luggage; and

 

3. You must provide us with copies of all documentation of the claim filed with the transportation provider, and a written statement from the transportation provider confirming that the luggage was checked and after careful search, the luggage remains missing; and

 

4. The lost checked luggage must be lost as of the date of our payment and as of that date, must have been lost for at least 10 days.

 

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

 

Lost or Stolen Passport/Travel Visa

 

YOU ARE COVERED:

1. Reimbursement for reasonable cost in replacing your passport or travel visa.

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You exercise reasonable care for the safety and supervision of the passport or travel visa; and

2. Loss or theft is reported to the police within 24 hours and a written police report is obtained; and

3. You provide receipts for the costs associated with the passport or travel visa replacement.

 

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

 

Natural Disaster - Replacement Accommodations

 

YOU ARE COVERED:

1. Replacement accommodations in the event you are displaced from planned paid accommodations due to evacuation from forecasted Natural Disaster or following a Natural Disaster strike.

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. Following receipt of proof of payment for the accommodations from which you were displaced.

 

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

 

Displaced means required to depart a destination due to an evacuation ordered by prevailing authorities.

 

Natural Disaster means an event of natural cause, including wildfire, earthquake, windborne dust or sand, volcanic eruption, tsunami, snow, rain or wind, that results in widespread and severe damage. Natural disaster does not include the direct or indirect effect of rain, wind or water associated with named storms meeting the definition of hurricane or typhoon, except in instances where:

1. The path of the named storm deviates by a distance of greater than 200 miles within a 72-hour period from the path forecast by a nationally recognized meteorological service

2. Or less than 72 hours advance notice of a potential landfall for a named storm exists.

 

Border Entry Protection

 

YOU ARE COVERED:

If you are traveling on a Visitor Visa B-2 for tourism, for visiting family or friends, or on holiday, and you are denied entry to the United States at the border by customs officials:

1. Reimbursement for the cost of an economy one-way air or ground transportation ticket to the original country of origin; or

 

2. Common carrier change fee to the original country of origin less the amount credited for any unused portion of the return travel arrangements.

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You must return to the country of origin; and

2. You must not be a citizen or of the United States, have home country of the United States, and/or have permanent residency in the United States.

 

YOU ARE NOT COVERED IF:

1. You are traveling to the United States without a Visitor Visa B-2, or you are travelling illegally; or

2. You are from a country named on any active executive order at the time of purchase; or

3. You are on the United States terror watch list; or

4. You were denied entry to the United States upon arrival or while en route to the United States because you have violated any rule, law, condition of or guideline regarding the visa upon which you are traveling; or

5. You are visiting the United States for medical treatment, participation by amateurs in musical, sports, or similar events or contests, if compensation is received; or

6. You are visiting the United States for studies that receive credits towards a degree; or

7. You committed a crime en route or upon entry to the United States which caused or would have caused you to be returned to your country of origin; or

8. The United States government or the common carrier has paid, offered to pay, or will pay for your repatriation to your country of origin; or

9. You have an unused return ticket or credit issued by the common carrier. If credit is not used, the amount reimbursed will be reduced by the amount of the credit.

 

Country of Origin means the country you were in when you first departed for the United States.

 

Executive Order means a rule or order issued by the United States President on how federal agencies are to use their resources and having the force of law.

 

Pet Return:

YOU ARE COVERED

1. The cost of a one-way economy air and/or ground transportation ticket for a pet to be returned to the terminal serving the area of your principle residence.

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You are the only person age 18 or older traveling with the pet; and

2. You are hospitalized for treatment of a covered illness or injury, resulting in the pet being left unattended for a period of time expected to exceed 36 hours.

YOU ARE NOT COVERED IF:

1. Expenses arise directly or indirectly from anything in the General Exclusions.

 

Leisure, Recreational, Entertainment, or Fitness Sports & Activities

 

 

YOU ARE COVERED:

1. You are covered for taking part in amateur/non-professional sports and activities, unless it is excluded below. Coverage is for recreational purposes incidental to a trip.

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You must ensure the activity is adequately supervised and that appropriate safety equipment (such as protective headwear, life jackets etc.) are worn at all times.

 

YOU ARE NOT COVERED IF:

1. The activity is organized athletics involving regular or scheduled practice and/or games; or

2. The activity is performed in a professional capacity or for any wage, reward, or profit; or

3. Expenses arise directly or indirectly from anything in the General Exclusions; or

4. Any of the excluded items listed below:

 

  • All-Terrain Vehicles
  • American Football
  • Aussie Rules Football
  • Aviation (except when traveling solely as a passenger in a commercial aircraft)
  • Base Jumping
  • Big Game Hunting
  • Bobsleigh
  • Boxing
  • Cave Diving
  • Hang-Gliding
  • Heli-Skiing
  • Hot Air Ballooning as a Pilot
  • Ice Hockey
  • Jousting
  • Kite-Surfing
  • Luge
  • Martial Arts
  • Modern Pentathlon
  • Motorized Dirt Bikes
  • Mountaineering at elevations of 4,500 meters or higher
  • Outdoor Endurance Events
  • Parachuting
  • Paragliding
    • Parasailing
    • Powerlifting
    • Quad Biking
    • Racing by any Animal, Motorized Vehicle, or BMX, and Speed Trials and Speedway
    • Rugby
    • Running with the Bulls
    • Skeleton
    • Sky Surfing
    • Snow Skiing and Snowboarding, except recreational downhill and/or cross-country snow skiing or snowboarding (no cover provided while skiing away from prepared and marked in-bound territories and/or against the advice of the local ski school or local authoritative body)
    • Snow Mobiles
    • Spelunking
    • Sub Aqua Pursuits involving underwater breathing apparatus unless accompanied by a certified instructor at depths less than 10 meters, or PADI/NAUI certified
    • Tractors
    • Whitewater Rafting
    • Wrestling

 

Personal Accident

Accidental Death and Dismemberment

YOU ARE COVERED:

1. Death – we will pay the amount indicated in the Schedule of Benefits to the beneficiary.

2. Loss of 2 or more limbs or eyes – we will pay you the amount indicated in the Schedule of Benefits.

3. Loss of 1 limb or eye – we will pay you the amount indicated in the Schedule of Benefits.

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The accident giving rise to the Accidental Death or Dismemberment must be covered under this insurance; and

2. The accident giving rise to the accidental death must not be a common carrier accident; and

3. Death must occur within 30 days of the sudden, unintentional and unexpected occurrence and not be contributed to by illness or disease.

 

YOU ARE NOT COVERED IF:

1. Accidents or loss caused by or contributed to by any of the following:

a. Terrorism, war or act of war, whether declared or undeclared.

b. Your participation in a riot, insurrection or violent disorder.

c. Your service in the armed forces of any country.

d. Suicide or attempted suicide or self-inflicted injury, while sane or insane.

e. The voluntary use of any chemical compound, poison or drug, unless used according to the directions of a physician.

f. Committing or attempting to commit a felony.

g. Sickness, mental health disorder, or pregnancy.

h. As the result of intoxication as defined by the laws of the jurisdiction in which the accident occurred, whether directly or indirectly,

i. Myocardial infarction or cerebrovascular accident (CVA / Stroke).

j. Infection, except infection through a wound caused solely by an accident.

k. Injury while riding, boarding, or alighting from an aircraft if you were operating the aircraft, learning to operate the aircraft, serving as a member of the aircraft crew, or if the aircraft was being used for any purpose other than passenger transportation.

l. Medical or surgical treatment for any of the above.

m. Any non-covered sports activities.

 

2. Expenses arise directly or indirectly from anything in the General Exclusions.

 

In no event will our payment under this benefit total more than the principal sum. The maximum liability under Accidental Death and Dismemberment for any group or family is limited to $250,000.

 

 

 

Common Carrier Accidental Death Benefit

YOU ARE COVERED:

1. The amount indicated in the Schedule of Benefits to the beneficiary.

 

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The accident giving rise to the accidental death must occur while you are a fare paying passenger on a regularly scheduled trip on board a commercial airline or cruise line; and

2. Death must occur with 30 days of the sudden, unintentional and unexpected occurrence and not be contributed to by illness or disease; and

3. The maximum liability under this Common Carrier Accidental Death Benefit for a group or family is limited to $250,000.

 

Accidental Death means a sudden, unintentional and unexpected occurrence caused solely by external, visible means resulting in physical injury to you and your subsequent death. Death must occur within 30 days of the sudden, unintentional and unexpected occurrence and not be contributed to by illness or disease.

Accidental Dismemberment means a sudden, unintentional and unexpected occurrence caused solely by external, visible means and resulting in complete severance from the body of one or more limbs or eyes and not contributed to by illness or disease. For purposes of the Accidental Death and Dismemberment benefit, the term “limb” shall mean: the arm when the severance is at or above (toward the elbow) the wrist, or the leg when the severance is at or above (toward the knee) the ankle. Loss of eye(s) shall mean: complete, permanent, irrevocable loss of sight.

Beneficiary means the individual named in your application to be the recipient of any Accidental Death or Common Carrier Accidental Death benefit. If you do not designate a beneficiary on the application, the beneficiary is automatically as follows:

Members age 18 or older: 1. Spouse (if any), 2. Children (if any) equally, 3. Your estate.

Members under age 18: 1. Custodial Parent(s) (if any), 2. Siblings (if any) equally, 3. Your estate.

Crisis Response

YOU ARE COVERED:

1. Ransom; and/or

2. Crisis Response Fees and Expenses; and/or

3. Personal Belongings

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

 

1. Notification: Before surrendering a ransom, the person authorizing the surrender shall have notified or made every reasonable attempt to notify:

a. The Federal Bureau of Investigation or local law enforcement agencies as soon as practicable bearing in mind the safety of the person(s) held or threatened; and

b. Unity Resources Group via us.

 

2. The surrender of a ransom must not be:

a. Carried by, transported by or otherwise in your possession at the time that an express kidnapping or kidnapping first occurs; or

b. At the location where an express kidnapping or kidnapping first occurs, unless brought to such location for the sole purpose of conveying a previously communicated ransom demand.

 

3. Confidentiality: You must at all times use best efforts to ensure that knowledge of the existence of this insurance is restricted as far as possible.

 

YOU ARE NOT COVERED IF:

1. Any kidnapping or express kidnapping first occurs in Afghanistan, Central African Republic, Democratic Republic of the Congo, Iraq, Libya, Mali, Niger, Nigeria, North Korea, Pakistan, Somalia, Sudan, South Sudan, Syria, Venezuela, Yemen, or any country for which we are prohibited from transaction due to sanctions by the United States Department of the Treasury’s Office of Foreign Assets Control (OFAC).

2. Any express kidnapping or kidnapping is a result of fraudulent, dishonest or criminal act(s) by you or an authorized representative (whether acting alone or in collusion with others) unless the person authorizing the ransom payment had, prior to payment, made every reasonable attempt to determine that the ransom demand or threat was genuine.

3. Expenses arise directly or indirectly from anything in the General Exclusions.

 

Limits of Liability:

1. Certificate Period Aggregate: Our total liability for all insured losses shall not exceed the certificate period aggregate set forth herein.

2. In the event that you are covered by two or more policies issued by us covering insured losses arising from a kidnapping or express kidnapping, it is agreed that our aggregate liability for insured losses sustained by you shall not be cumulative and shall in no event exceed the largest amount available under any one of the policies

 

Valuation: We shall not be liable for more than the actual cash value of any consideration at the time of its surrender. If insured losses involve currency other than that of the United States of America, we shall not be liable for more than the United States Dollar equivalent of foreign currency based on the rate of exchange in the Wall Street Journal in effect on the day the monies are surrendered and/or expense incurred.

 

Crisis Response Fees and Expenses means all fees and expenses of Unity Resources Group related to your kidnapping or express kidnapping.

 

Express Kidnapping means the actual or attempted abduction and holding of you against your will where your personal belongings and/or readily available assets are surrendered by you in exchange for your release.

 

Kidnapping means the actual, alleged, or attempted abduction and holding of you against your will by a person or persons who demand a ransom specifically from your assets in exchange for your release.

 

Insured Losses means covered losses and expenses consisting of the following: ransom, personal belongings, and/or crisis response fees and expenses.

 

Personal Belongings means monies and/or property of monetary value that are:

1. Being carried or transported by you when an express kidnapping or kidnapping first occurs; and

 

2. Are surrendered during the course of an express kidnapping or kidnapping.

 

Ransom means monies and/or other consideration of monetary value that are surrendered or to be surrendered by you or on your behalf to meet an express kidnapping or kidnapping demand.

 

Personal Liability

 

YOU ARE COVERED:

Up to the sum insured shown in the Schedule of Benefits and Limits (inclusive of legal costs and expenses) if you become legally liable to pay damages in respect of:

1. Accidental bodily injury, including death, illness and disease to a third person; and/or

2. Accidental loss of or damage to a third person’s material property (property that is both material and tangible); and/or

 

3. Accidental loss of or damage to a related third person’s material property (property that is both material and tangible);

 

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. You or your legal representatives will give us written notice immediately if you have received notice of any prosecution or inquest in connection with any circumstances which may give rise to liability under this section.

 

2. No admission, offer, promise, payment or indemnity shall be made by or on behalf of you without our prior written consent.

 

3. Every claim notice, letter, writ or process or other document served on you shall be forwarded to us and immediately upon receipt.

 

4. We shall be entitled to take over and conduct in your name the defense or settlement of any claim or to prosecute in your name for our own benefit any claim for indemnity or damages against all other parties or persons.

 

5. We may at any time pay you in connection with any claim or series of claims the sum insured (after deduction of any sums already paid as compensation) or any lesser amount for which such claim(s) can be settled. Once this payment is made we shall relinquish the conduct and control and be under no further liability in connection with such claim(s) except for the payment of costs and expenses recoverable or incurred prior to the date of such payment.

 

6. We will consider paying or advancing, but without any obligation or contractual duty to do so, up to $2,500 to you or for your benefit to settle and compromise an asserted claim against you so long as:

a. The asserted claim is one that may be eligible for coverage under this insurance;

b. A lawsuit has not yet been filed, or, if already filed, no response has been filed;

c. You obtain a full written release and/or covenant-not-to-sue satisfactory to us; and

d. A full proof of claim and other necessary documentation is satisfactorily provided to us.

 

YOU ARE NOT COVERED FOR:

 

1. Intentionally committed acts, or arising from the influence of alcohol or drugs not medically prescribed by a licensed physician;

 

2. Bodily injury, illness or disease of any person under a contract of employment, service or apprenticeship with you when the bodily injury, illness or disease arises out of and in the course of their employment to you, or in connection with any trade, business or profession;

 

3. Loss or damage to property belonging to or held in trust by or in the custody or control of you other than temporary accommodation occupied by you in the course of the trip;

 

4. Bodily injury or damage caused directly or indirectly in connection with the ownership, possession or use by you or on behalf of you of: aircraft, hovercraft, watercraft, motorized vehicles, parachute, parasail, glider, firearms, fireworks, explosives, deadly weapons, or any racing activity;

 

5. Any damages, losses or claims caused in whole or in part by you during any hunt or as a result of hunting;

 

6. Bodily injury caused directly or indirectly in connection with the ownership, possession or occupation of land or buildings, immobile property or caravans or trailers;

 

7. Damages resulting from any fire, flood, wind, hail, waterleak, gas leak, explosion or other catastrophe;

 

8. Fraudulent, dishonest or criminal acts of you or any person authorised by you;

 

9. The consequences of any breach, violation or failure to perform any contractual undertakings or obligations, whether verbal or in writing;

 

10. Punitive or exemplary damages, or fines, penalties, assessments or claims by any governmental authorities or regulatory bodies;

 

11. Gambling, gaming, or betting of any kind;

 

12. Animals or pets belonging to you, or in your care, custody or control;

 

13. Expenses arise directly or indirectly from anything in the General Exclusions.

 

Third Person means any individual, natural person, or other legal entity or person, other than you or a related third person.

 

Related Third Person means your relative, your traveling companion a relative of such traveling companion’s relative, and any other person, individual or family member with whom you are residing or being hosted.

 

 

Article 12 - Terrorism

 

YOU ARE COVERED:

1. Eligible Medical Expenses for treatment of injuries and illnesses resulting from an Act of Terrorism, up to the limit set forth in the Schedule of Benefits and Limits, provided all of the following conditions are met.

YOU ARE NOT COVERED unless you fulfill the following conditions:

1. The injury or illness does not result from the use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon;

2. You have no direct or indirect involvement in the Act of Terrorism;

3. The Act of Terrorism is not in a country or location where the U.S. Department of State has issued a level 3 or level 4 travel advisory that has been in effect within the 6 months immediately prior to your date of arrival; and

4. You have not failed to depart a country or location within 10 days following the date a level 3 or level 4 travel advisory for that country or location is issued by the United States government.

 

YOU ARE NOT COVERED IF:

1. Loss, damage, cost or expense directly or indirectly caused by, resulting from or in connection with any of the following regardless of any other cause or event contributing concurrently or in any other sequence to the loss, damage, cost or expense:

a. War, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power; or

b. The use of any biological, chemical, cyber, radioactive or nuclear agent, material, device or weapon; however, this exclusion shall not apply where you are exposed to nuclear radioactive and/or radioactive material for the purpose of medical treatment; or

c. Any Act of Terrorism, not specifically covered above; or

d. Coverage for loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to (a), (b) or (c) above; or

e. Expenses arise directly or indirectly from anything in the General Exclusions.

 

For the purpose of this insurance, an “Act of Terrorism” means an act, including but not limited to, the use of force or violence and/or the threat thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political, religious, ideological or similar purposes including the intention to influence any government and/or to put the public, or any section of the public, in fear.

 

If we allege that by reason of this exclusion, any loss, damage, cost or expense is not covered by this insurance, the burden of proving the contrary shall be upon you.

 

In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.

 

Cyber means the use or operations, as a means for inflicting harm, of any computer, computer software program, malicious code, computer virus or process or any other electronic system.

General Exclusions

Excluded Conditions, Treatments (includes Diagnoses, Tests, and Examinations), Services, Supplies, Acts, Omissions, and/or Events:

1. Pre-existing Conditions, except charges resulting directly from an Acute Onset of Pre-existing Condition, as herein defined, subject to the limits set forth in the Schedule of Benefits and Limits.
2. Birth defects and congenital illnesses. Birth defects are deemed to include hereditary conditions.
3. Mental health disorders.
4. Pregnancy except as covered under Complications of Pregnancy, as herein defined, termination of pregnancy except in connection with covered Complications of Pregnancy, all charges related to
pregnancy after the 26th week of pregnancy, routine prenatal care, child birth, postnatal care, and charges incurred by a child under the age of 14 days.
5. Impotency or sexual dysfunction.
6. All sexually transmitted diseases and conditions.
7. HIV, AIDS, or ARC, and all diseases caused by and/or related to HIV.
8. All forms of cancer / neoplasm.
9. Substance abuse or addiction or conditions that may be attributed to substance abuse or addictions and direct consequences thereof.
10. Acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, hypertrophic and atrophic conditions of skin, nevus.
11. Sleep apnea or other sleep disorders.
12. Obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass surgery.
13. Self-inflicted injury or illness and/or suicide or attempted suicide whether sane or insane.
14. Injury sustained that is due wholly or partially to the effects of intoxication or drugs other than drugs taken in accordance with treatment prescribed by a physician and except drugs prescribed for the treatment of substance abuse.
15. Injury sustained while operating any motorized vehicle, aircraft or watercraft whether registered or not while under the influence of alcohol as defined under the law of the jurisdiction where the injury occurs or with a .08 BAC Blood Alcohol Content, whichever is lower.
16. Routine medical examinations, including but not limited to vaccinations, immunizations, annual check-ups, the issue of medical certificates and attestations, and examinations as to the suitability of employment or travel.
17. Dental treatment and treatment of the temporomandibular joint, except for emergency dental treatment necessary to replace sound natural teeth lost or damaged in an accident covered hereunder or for the emergency relief of acute onset of pain.
18. Promotion or prevention of conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
19. Organ or tissue transplants or related services.
20. Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
21. Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations, except as provided for under Emergency Eye Exam.
22. Orthoptics and visual eye training.
23. Orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or toenails.
24. Hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed.
25. Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinesiotherapy.
26. Psychometric, intelligence, competency, behavioral and educational testing.
27. Cosmetic or aesthetic reasons, except for reconstructive surgery when such surgery is directly related to and follows a surgery which was covered hereunder.
28. Modifications of the physical body intended to improve the psychological, mental or emotional well-being, including but not limited to sex-change surgery.
29. Exercise programs, whether or not prescribed or recommended by a physician.
30. Incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
31. Cryo preservation and implantation or re-implantation of living cells.
32. Genetic or predictive testing.
33. Investigational, experimental or for research purposes.
34. While confined primarily to receive custodial care, educational or rehabilitative care, or any medical treatment in any establishment for the care of the aged, except rehabilitative care received upon direct transfer from an acute care hospital.
35. Not medically necessary.
36. Not administered by or under the supervision of a physician, and products that can be purchased without a doctor's prescription.
37. Provided by a relative, family member or any person who ordinarily resides with you.
38. Provided at no cost to you.
39. Telephone consultations or failure to keep a scheduled appointment.
40. Payable under any government system, including the Australian Medicare system.
41. Charges exceeding usual, reasonable and customary.
42. Charges resulting from or occurring during the commission of a violation of law, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
43. Charges resulting from a disease outbreak in a country or location for which the U.S. Centers for Disease Control and Prevention (CDC) has issued a Level 3 Travel Warning if a) the warning has been in effect within the 6 months immediately prior to your date of arrival, or b) within 10 days following the date the warning is issued you have failed to depart the country or location.
44. Any illness or injury incurred as a result of epidemics, pandemics, public health emergencies, natural disasters, or other disease outbreak conditions that may affect a person’s health when prior to your effective date, any of the following were issued:
a. The United States Centers for Disease Control & Prevention had issued a Warning/Alert Level 3 or higher for a location or destination, including common carriers; or
b. The United States Centers for Disease Control & Prevention had issued a Global or Worldwide Warning/Alert Level 3 or higher.
This exclusion is applicable when 1) any of the above were in effect within 6 months immediately prior to your effective date or 2) within 10 days following the date the alert/warning is issued you have failed to depart the country or location. This exclusion does not apply to charges resulting from COVID-19/SARS-CoV-2.
45. Travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Repatriation of Remains, Emergency Reunion, Natural Disaster, Return of Minor Children, Political Evacuation, Trip Interruption, Travel Delay, and Border Entry Protection sections of this insurance.
46. Incurred outside your certificate period.
47. Submitted to us for payment more than 60 days after the last day of the certificate period.
48. When departure from the home country is to obtain treatment in the destination country/countries.
49. Complications or consequences of a treatment or condition not covered hereunder.
50. Not included as Eligible Expenses as described herein.
51. Payable under Worker’s Compensation or Employer’s Liability Laws, or by any coverage provided or required by law

Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions) (only available to members under age 80)

Up to the overall maximum limit

Up to $25,000 lifetime maximum for Emergency Medical Evacuation

PRE-EXISTING MEDICAL CONDITIONS

This policy does not cover pre-existing conditions, except charges resulting directly from an Acute Onset of Pre-existing Condition subject to the limits set forth in the Schedule of Benefits and Limits.

Pre-existing Condition means any

  1. Condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the
  2. 2 years immediately preceding the certificate effective date; 2. Condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 2 years immediately preceding the certificate effective date; or
  3. 3. Injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 2 years immediately preceding the certificate effective date. For the purposes of the Complications of Pregnancy coverage offered hereunder, pregnancy will not be included within the definition of a pre-existing condition

 

ACUTE ONSET OF PRE-EXISTING CONDITION YOU ARE COVERED:

1. Charges for a sudden and unexpected outbreak or recurrence of a pre-existing condition(s) which:

a. Occurs when you are under age 80; and

b. Occurs spontaneously and without advance warning either in the form of physician recommendations or symptoms; and

c. Is of short duration; and

d. Is rapidly progressive; and

e. Requires urgent care. YOU ARE NOT COVERED unless you fulfill the following condition:

1. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence.

YOU ARE NOT COVERED IF:

1. The Acute Onset of a Pre-existing Condition(s) occurs before the certificate effective date; or

2. The pre-existing condition is

• a chronic or congenital condition; or

• a complication or consequence of a chronic or congenital condition; or

• a condition that gradually becomes worse over time; or

3. The charges are for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the certificate effective date; or

4. Expenses arise directly or indirectly from anything in the General Exclusions.

 

You may review a listing of hospitals, physicians and other medical service providers included in the PPO Network for the area where you will be receiving treatment by accessing the Internet website for Tokio Marine HCC Medical Insurance Group at:

You may extend policy online before expiration date of policy. You may extend minimum of 5 days. Insurance company charge $5 extension fee for each renewal. Total coverage duration cannot be more than 364 days including extension.

We hope you are happy with the cover this policy provides. However, if after reading it, this insurance does not meet with your requirements, please notify us of your wish to cancel and we will refund your premium.

Premiums will be refunded in full if cancellation request is received prior to the certificate effective date.

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

  1. A $25 cancellation fee will apply for administrative costs incurred by us; and
  2. Only the unused portion of the plan cost will be refunded; and
  3. You cannot have filed any claims to be eligible for premium refund.

Article 9 - Claim Procedures

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

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

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

Proof of Claim

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

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

Beginning on the last day of your certificate period, you shall have 60 days to provide us proof of claim (unless medical services were rendered after the certificate termination date, in which case you shall have 60 days from the date the claim is incurred). Subsequent to receipt of proof of claim, we may, at our sole discretion, request and require additional information, including but not limited to medical records, necessary to confirm the validity of any claim prior to payment thereof.

Claims Cooperation

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

Access to Additional Materials

You shall provide us, or our designated representatives, all information, documentation, medical information that we or they may reasonably require during the term of this policy, or until all claims have been resolved, whichever is later.

Other Insurance

We shall not pay any claim if there is other insurance which would, or would but for the existence of this insurance, pay such claim. This insurance will apply with respect to expenses in excess of the amount paid or payable under such other insurance. We shall not pay any claim in respect to care, treatment, services or supplies furnished by any program or agency funded by any government

Arbitration

Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration by the American Arbitration Association in accordance with its Consumer Arbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Where any dispute is by this provision referred to arbitration, the making of an award shall be a condition precedent to any right of action against us.

Subrogation

You undertake to cooperate with us in the prosecution of any and all valid claims you may have against third parties arising out of any occurrence which results or may result in a loss payment by us and to account for any amounts recovered on the basis that we are entitled to recover first in full any sums paid by them before you share in any amount so recovered. Should you fail to prosecute any valid claims against third parties and we thereupon become liable to make payment under this insurance, then we shall be subrogated to all your rights. Any amount recovered us shall be used to pay the expenses of collection and reimburse us for any amount that we may have paid or become liable to pay under this insurance. Any remaining amounts shall be paid to you.

Right of Recovery

In the event of overpayment of any claim hereunder because:

1. all or some of the expenses were not paid for by you or on your behalf or were subsequently recovered by you or on your behalf; or
2. any relative of you or any person in your family, whether or not that person is or was a member, is repaid for all or some of those expenses by a source other than us; or
3. all or some of the expenses were not Eligible Expenses; or
4. all or some of the expenses were paid or reimbursed based on incorrect benefit application.

We have the right to recover the amount of overpayment from you and/or the hospital, physician or other provider of services or supplies. The amount of the recovery is the difference between:

1. the amount of expenses actually paid by us; and
2. the amount of expenses which should have been paid by us.

If you or the hospital, physician or other provider of services or supplies does not promptly make any such refund to us, we may, in addition to any other remedies available, either:

1. reduce the amount of any future claim that is otherwise eligible for payment hereunder, to the full extent of the refund due to us; or
2. cancel this certificate issued to you by giving 30 days advance written notice by mail to your last known address.

Claims Assistance

Every attempt will be made to help you understand the benefits provided by this insurance, however, any statement made by our employee will be deemed a representation and not a warranty. Actual benefit payment can only be determined at the time a claim is submitted and all facts are presented in writing. If a definite answer to a specific question is required, you can submit a written request, including all pertinent information and a statement from the attending physician (if applicable), and a written reply will be sent to you and kept on file.

Patient Advocacy

We may determine that a particular claim or diagnosis occurring under this insurance may be placed under the Patient Advocacy program to ensure that medically necessary services and supplies are provided in the most cost-effective manner. In the event we determine that a claim or diagnosis meets the Patient Advocacy program requirements, we will notify you, and a Patient Advocate will be assigned. Thereafter, the Patient Advocate may make recommendations of alternative treatment settings and/or procedures and/or supplies, which may be more cost effective for us and/or you. Such recommendations will be made with input from you and your physician(s) and will be made only when it can be reasonably demonstrated that the medically necessary services and supplies can be provided in a more cost-effective manner to us and/or you. We will use best efforts to evaluate and recommend alternative treatment settings and/or procedures and/or supplies, which can reasonably be expected to result in the same or better care for you. You, in accepting the recommendations, agree to hold us harmless and we shall not be held liable or otherwise responsible for any treatment, service, supply, procedure or care provided to you except for the payment of benefits under this insurance. After you have been notified that the claim or diagnosis meets the Patient Advocacy program requirements, we reserve the rights to:

1. Make payment for treatments, services and/or supplies which are not covered under this insurance which would be beneficial to you and cost effective to us; and
2. Deny payment for expenses which would otherwise be covered under this insurance which are over the amount we would have paid had you followed the recommendations of the Patient Advocacy program.

Article 10 – Appeals and Complaints Procedure

APPEALING A CLAIM: In the event we deny all or part of a claim under this insurance, you may file a written appeal with us. The written appeal must include sufficient information to identify the claim under appeal and must specify the reason(s) for the appeal with supporting documentation, if applicable.

Please provide your written appeal online, by email, or by postal mail at the following:

Online: http://service.hccmis.com/
Email: mis-appeals@tmhcc.com
Postal Mail: Tokio Marine HCC
Appeals P.O. Box 2058 Farmington Hills, MI 48333 USA

When we receive the appeal, we will review the claim and a written response will be sent to you. After you receive our response to the appeal, you may initiate a second appeal. With our receipt of the second appeal, medical and/or claims personnel who were not involved in the original claim determination or the initial appeal will review the claim. A final determination will be made and a letter will be sent to you.

Please note that appealing a claim is not a requirement to following the complaints procedure detailed below.

Complaints Procedure

We are dedicated to providing a high-quality service and want to ensure that it is maintained at all times. If you feel that we or another party connected with this policy have not offered a first-class service please contact us and we will do our best to resolve the problem.

Please provide your written complaint online or by postal mail at the following:
http://service.hccmis.com/ or Tokio Marine HCC - MIS Group
P.O. Box 2005
Farmington Hills, MI 48333-2005
USA

You will be contacted within 3 (three) business days of receiving your complaint to inform you of what action is being taken. We will try to resolve the problem and give you an answer within four weeks. If it will take longer than four weeks we will tell you when you can expect an answer. If you have not been given an answer within 8 (eight) weeks we will tell you how you can take your complaint to the Financial Ombudsman Service for review. This complaints procedure does not affect any legal right you have to take action. Once you have received your final response from us, and if you are still not satisfied you can contact the Financial Ombudsman Service:

Financial Ombudsman Service
Exchange Tower, Harbour Exchange Square, London, E14 9SR
Phone: +44 (0) 20 7964 0500
Email: complaint.info@financial-ombudsman.org.uk

If you have purchased your policy online or by other electronic means within the European Union (EU) you may also make your complaint via the EU’s online dispute resolution (ODR) platform. The website for the ODR platform is: http://ec.europa.eu/odr

ARBITRATION AND CLASS ACTION WAIVER

Excluding claims for injunctive or other equitable relief, any dispute or controversy between a Member and any of the MIS Group, Underwriters or their affiliates arising out of or relating to this Master Policy, including without limitation, any and all disputes, claims (whether in tort, contract, statutory or otherwise) or disagreements concerning the existence, breach, interpretation, application or termination of this Master Policy, shall be resolved by final and binding arbitration pursuant to the Federal Arbitration Act and in accordance with the JAMS Inc. Comprehensive Arbitration Rules & Procedures then in effect. Such claims shall be arbitrated on an individual basis only and the parties waive any right or authority for any claims to be resolved in a class, consolidated, representative, collective or private attorney general action or arbitration. Instructions regarding how to commence an arbitration are available on the JAMS website, located at https://www.jamsadr.com. The arbitration shall take place in Houston, Texas or at the option of the party seeking relief, by telephone, online, or via written submissions alone, and be administered by JAMS. The arbitral tribunal (“Tribunal”) shall be composed of one arbitrator, who shall be independent and impartial. If the parties fail to agree on the arbitrator within twenty (20) calendar days after the initiation of an arbitration hereunder, JAMS shall appoint the arbitrator. The arbitration shall be conducted in the English language. The decision of the arbitrator will be final and binding on the parties. Judgment on any award(s) rendered by the arbitrator may be entered in any court having jurisdiction thereof. The arbitrator shall have the authority to determine arbitrability of any disputes arising out of or relating to this Master Policy. Nothing in this Section shall prevent either party from seeking immediate injunctive relief from any court of competent jurisdiction, and any such request shall not be deemed incompatible with the agreement to arbitrate or a waiver of the right to arbitrate. The parties undertake to keep confidential all awards in their arbitration, together with all confidential information, all materials in the proceedings created for the purpose of the arbitration and all other documents produced by the other party in the proceedings and not otherwise in the public domain, save and to the extent that disclosure may be required of a party by legal duty, to protect or pursue a legal right or to enforce or challenge an award in legal proceedings before a court or other judicial authority. The arbitrator shall award all fees and expenses, including reasonable attorney’s fees, to the prevailing party. This agreement to arbitrate does not apply to claims Members may have for medical malpractice against their medical providers.

Members may choose to opt out of the agreement to arbitrate by mailing a written opt-out notice (“Notice”) to Tokio Marine HCC – MIS Group. The Notice must be postmarked no later than sixty (60) days after the last day of your certificate period. The Notice must be mailed to: HCC Insurance Holdings, 13403 NW Freeway, Houston, Texas 77040, to the attention of General Counsel. This procedure is the only mechanism by which you can opt out of the agreement to arbitrate. Opting out of the agreement to arbitrate has no effect on any other parts of this Master Policy, or any previous or future arbitration agreements that you have entered into with Tokio Marine HCC-MIS Group.

No coverage available for these countries when selected on application as home country, citizenship country or destination country.

  • Cuba
  • Iran
  • North Korea
  • Sudan