ELIGIBILITY

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) 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 and/or Child

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

 (3) receive written acceptance of his/her Application or renewal from the Company

(4) be at least fourteen (14) days old but not yet seventy-five (75) years old

(5) not be Pregnant, Hospitalized or Disabled on the Initial Effective Date

(6) not be HIV+ on the Initial Effective Date

(7) United States citizens: must be residing outside of the United States as of the Effective Date (or renewal date) and plan to reside outside of the United States for at least six (6) of the next twelve (12) months thereafter

(8) Non-United States citizens:

(a) must reside outside the United States at time of Application (or renewal);

(b) must plan to reside outside of the United States continuously for at least six (6) months during the Period of Coverage with required departure from the United States not more than thirty (30) days after the Initial Effective Date or renewal Effective Date; or

 (c) if located inside the United States at the time of Application (or renewal), must not be eligible for any other medical insurance plan which is available to individuals similarly situated and located in the United States and must provide the Company an Affidavit of Eligibility.

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 next day following the end of the coverage period for which Premium has been fully and timely paid

(b) the termination date as shown on the Declaration for this Certificate

(c) the date the Master Policy is terminated pursuant to the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF MASTER POLICY provision

(d) the date the Insured Person becomes a resident alien under IRS regulations or 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 30th day after the Effective Date of this Certificate, if the Insured Person is not a citizen of the United States but is located in the United States at the time of Application and has not departed the United States prior to such 30th day, unless the Insured Person is not eligible for any other medical insurance plan which is available to individuals similarly situated and located in the United States and has provided the Company an Affidavit of Eligibility

(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, 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.

BENEFIT SUMMARY:  The following benefits and coverage are available to the Insured Person, subject to the AGREEMENT provision, while the insurance plan shown in the Declaration is in effect.

AGREEMENT:  Sirius International Insurance Corporation (publ) (the Company) promises and agrees to provide the Insured Person with the benefits described in the Master Policy, as outlined herein and coverage for which is certified hereunder by the Company.  The Company makes this promise and agreement in consideration of the Assured's Application, the accuracy and truthfulness of the Insured Person's Application and payment of Premium, and subject to all of the Terms of the Master Policy and any Riders.  The Master Policy is effective as of January 1, 2018 and shall remain in effect until terminated in accordance with the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF MASTER POLICY provision.  This Certificate shall be effective as of the Effective Date of Coverage shown on the Declaration and shall remain in effect until terminated in accordance with the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF COVERAGE FOR INSURED PERSONS provision.  This Certificate is not part of the insurance contract.  The contract is the Master Policy, the Application, and any applicable Riders.  This Certificate is merely a description of and evidence of the Insured Person’s rights and benefits under the contract.  The Declaration likewise is evidence of the coverage under the contract and a statement of the Effective Date of Coverage, subject always to the Terms of coverage contained within the contract.  The Company hereby recognizes International Medical Group®, Inc., as the Company’s authorized representative and as the Plan Administrator of the Master Policy and this Certificate.  Subject to the Terms of the CONDITIONS AND GENERAL PROVISIONS, SERVICE OF SUIT; VENUE; CHOICE OF LAW; TRIAL BY COURT provision, all communications, notices and payments to the Company that are required or permitted under the Master Policy and/or as described in this Certificate shall be transmitted through the Plan Administrator, and receipt of same by the Plan Administrator shall be considered receipt by the Company.  SURPLUS LINES NOTICE: This insurance is issued pursuant to applicable surplus lines law.  Persons insured by surplus lines carriers do not have the protection of state Insurance Guaranty laws to the extent of any right of recovery for the obligation of an insolvent unlicensed insurer.

CONDITIONS AND GENERAL PROVISIONS:  The following Terms are conditions precedent to the Company's liability under the insurance provided to the Insured Person pursuant to and in accordance with the Terms of the Master Policy, as outlined by this Certificate (such insurance being sometimes referred to herein as “this insurance” or “the plan”):

ENTIRE AGREEMENT:  The Master Policy, including the Application, the Declaration and any Riders, shall constitute the entire agreement among the Company, the Assured, and the Insured Person.  This Certificate, including the Application, the Declaration, and any Riders, is an outline and evidence of the insurance provided by the Master Policy.  This Certificate does not extend or change the coverage provided by the Master Policy.  The insurance evidenced by this Certificate is subject to all Terms of the Master Policy, including the Application and any Riders.

PREMIUM:  Payment of required Premium shall be remitted to the Company:

(a) on or before the Due Date(s) specified on the Declaration

 (b) on or before any renewal date subject to the CONDITIONS AND GENERAL PROVISIONS, RENEWAL; AMENDMENTS provision

(c) prior to any reinstatement under the CONDITIONS AND GENERAL PROVISIONS, REINSTATEMENT OF COVERAGE FOR INSURED PERSONS provision

A grace period of ten (10) days (notwithstanding intervening Saturdays, Sundays or legal holidays) will be allowed for the payment of each installment of Premium, including Renewal Premium, except the first installment of the first Period of Coverage.  If any Premium is unpaid at the end of the grace period, all insurance coverage and benefits under this insurance shall lapse and terminate with effect from the initial Due Date of the unpaid Premium, and the Company shall have no liability to the Insured Person for any claims incurred on or after such date.  Premium is considered paid on the date the payment is actually received by the Company

ASSIGNMENT, CHANGE OR WAIVER:  Notwithstanding any law, statute, judicial decision, or rule to the contrary which may be or may purport to be otherwise applicable within the jurisdiction, locale or forum state of any healthcare or medical service provider, no transfer or assignment of any of the Insured Person's rights, benefits or interests under this insurance  shall be valid, binding on or enforceable against the Company or Plan Administrator unless first expressly agreed and consented to in writing by the Company.  Any such purported transfer or assignment not in compliance with the foregoing Terms shall be void ab initio and without effect as against the Company or Plan Administrator, and the Company shall have no liability of any kind under this insurance to any such purported transferee or assignee with respect thereto.  The Terms of the Master Policy as evidenced by this Certificate shall not be waived or modified except by the express written agreement of the Company.

SERVICE OF SUIT; VENUE; CHOICE OF LAW; TRIAL BY COURT:  No action at law or in equity can be brought by an Insured Person to recover on the contract of insurance prior to the later of (a) expiration of sixty (60) days after written Proof of Claim has been furnished in accordance with the contract of insurance or (b) exhaustion of one (1) appeal under the CONDITIONS AND GENERAL PROVISIONS, APPEALING A CLAIM provision above.  No action at law or in equity can be brought after the expiration of three (3) years after the time written Proof of Claim is required to be furnished under the contract of insurance.  The contract of insurance between the Insured Person and the Company, as represented by the Master Policy and evidenced by this Certificate, shall be deemed issued, finalized and made in Indianapolis, Indiana.  Sole and exclusive jurisdiction and venue for any court action or administrative proceeding relating to this insurance shall be in Marion County, Indiana, for which the Insured Person expressly consents.  The subjects, risks and benefits of insurance covered by the Master Policy and evidenced by this Certificate are not intended or considered by the Insured Person or the Company (or the Plan Administrator) to be resident, located, or performed in any particular State of the United States.  Indiana surplus lines law shall govern all rights and claims raised under this Certificate of Insurance.

In the event of the failure of the Company to provide benefits or pay or reimburse any amount claimed to be due under this insurance, the Company, at the request of the Insured Person and upon receipt of lawful process or summons, will submit to the jurisdiction of a court of competent subject matter jurisdiction located in Marion County, Indiana, provided there exists an independent statutory and constitutional basis for in personam jurisdiction over the Company in said court and by said forum State.  The Company and the Insured Person consent to personal jurisdiction and venue in the Circuit and/or Superior Courts of Marion County, Indiana, and in the United States District Court for the Southern District of Indiana, Indianapolis Division (assuming that federal jurisdiction is otherwise appropriate and lawful).  All trials regarding any dispute under this insurance shall be exclusively presented to and determined solely by the court as the trier of fact, without a jury.  The Company reserves the right, acting by and through the Plan Administrator, to initiate and pursue actions for declaratory judgment and/or other appropriate relief with respect to the validity, binding effect, administration of and/or any dispute or controversy arising under this insurance.  In any suit instituted by or against the Company or the Insured Person pursuant to the Terms of this provision, the Company and the Insured Person will abide by the final decision of such Indiana court or of any appellate court in the event of an appeal.

Nothing in this provision constitutes or should be deemed, considered or understood to constitute a waiver of the Company's or the Insured Person’s rights to: (i) oppose venue, procedural and/or substantive choice of law, personal jurisdiction, or subject matter jurisdiction in any forum other than the Circuit or Superior Courts of Marion County, Indiana, or the United States District Court for the Southern District of Indiana, Indianapolis Division (assuming that federal jurisdiction is otherwise appropriate and lawful), (ii) commence an action in any court of competent jurisdiction in or outside of the United States, (iii) remove an action to a United States District Court, or (iv) seek transfer of a case to another court or forum as permitted by the laws of such forum or the laws of the United States or of any State in the United States, as applicable; all of which rights are expressly reserved and retained.

Subject to and without limiting, expanding, superseding, modifying or waiving any of the foregoing Terms contained in this provision pursuant to any statute of any State, territory or district of the United States which makes provision thereof, the Company hereby designates the Superintendent, Commissioner, or Director of Insurance (or such other officer specified for that purpose in the statute), or his successor or successors in office, as its true and lawful attorney, under a special power of attorney, upon whom may be served any lawful process issued in connection with the initiation of any action, suit or proceeding instituted by or on behalf of the Insured Person arising out of this insurance, including specifically the Commissioner of Insurance for the Indiana Department of Insurance, 311 West Washington Street, Suite 300, Indianapolis, IN 46204, and hereby designates and appoints John P. Dearie, Jr., Esq., Locke Lord, LLP, 750 Lexington Avenue, New York, New York 10022, as its attorney-in-fact and agent for service of process to whom said officer or Commissioner is authorized to mail or serve any such process or a true copy thereof

For Florida residents only:  If any dispute shall arise as under the terms and conditions of this Certificate, such dispute may be referred to arbitration in accordance with the procedures of the American Arbitration Association.  Any such arbitration shall be held within fifty (50) miles of the Insured Person’s residence, with the Company to pay costs and fees (not including any attorney fees) of the proceeding in excess of $500.00.

MISREPRESENTATION:  Any false representation, incomplete information, misleading statement, misstatement, omission, concealment or fraud, whether or not innocently made, either in the Insured Person's Application which forms a part of the Master Policy and this Certificate, or in relation to any claim form, statement, certification or warranty made by the Insured Person or his/her representatives, agents or proxies, whether in writing or otherwise, to the Company or the Plan Administrator or their respective agents, employees or representatives, or in connection with the making of any claim under this insurance, shall render the Declaration and this Certificate null and void and all claims and benefits under this insurance shall be forfeited and waived.

INSOLVENCY:  The insolvency, bankruptcy, financial impairment, receivership, voluntary plan of arrangement with creditors or dissolution of the Assured or any Insured Person shall not impose upon the Company any liability or obligation other than that specifically included in this insurance.

SUBROGATION CLAUSE:  The Insured Person shall undertake to pursue in his/her own name and stead, and to fully cooperate with the Company in the pursuit and prosecution of, any and all valid claims that the Insured Person may have against any third party who may be liable or responsible for any loss or damage arising out of any act, omission or occurrence which results or may result in a loss payment, provision of benefits, or coverage of claim by the Company under this insurance, and to fully account to the Company for any amounts recovered or recoverable in connection therewith, on the basis that the Company shall be reimbursed and entitled to recover first in full for any sums paid or to be paid by it before the Insured Person shares in any amount so recovered.

The Insured Person further agrees and understands that the Company requires the Insured Person to complete a subrogation questionnaire, sign an acknowledgment of the Company's subrogation rights and sign an agreement before the Company considers paying, or continues to pay, any claims.  Should the Insured Person fail to so cooperate, account, or to prosecute any valid claims against any such third party or parties, and the Company thereupon or otherwise becomes liable or otherwise obligated to make payment under the Terms of this insurance, then the Company shall be fully subrogated to all rights and interests of the Insured Person with respect thereto and may prosecute such claims in its own name as subrogee

The Insured Person’s submission of Proof of Claim or acceptance of coverage or benefits under this insurance shall be deemed to constitute an authorization, consent and assignment of such subrogation rights by the Insured Person to the Company.  The Insured Person agrees the Company has a secured proprietary interest in any settlement proceeds the Insured Person receives or may be entitled to receive

The Insured Person understands and agrees the Company is entitled to a constructive trust interest in the proceeds of any settlement or recovery.  The Insured Person agrees to include the Company as a co-payee on any settlement check or check from any third party or insurer.  The Insured Person agrees he/she will not release any party or their insured without prior written approval from the Company, and will take no action which prejudices the Company's rights.

The Insured Person is obligated to inform their legal representative of the Company’s rights and lien and to make no distributions from any settlement or judgment which will in any way result in the Company receiving less than the full amount of its lien without the written approval of the Company.  Any amount recovered by the Company in accordance with the foregoing shall first be used to pay in full the costs and expenses of collection incurred by the Company, including reasonable attorneys’ fees, and for reimbursement to the Company for any amount that it may have paid or become liable to pay under this insurance.  Any remaining amounts recovered shall be paid to the Insured Person or other persons lawfully entitled thereto, as applicable.  In the event that the Insured Person receives any form or type of settlement and either fails or refuses to abide by the Terms of this insurance contract, in addition to any other remedies the Company may have, the Company retains a right of equitable offset against future claims.

APPLICABLE CURRENCY:  All benefit amounts, coverage, monetary limits and sub-limits, and other amounts stated in the Master Policy, the Application, the Declaration, this Certificate, and in any Riders, including Premium, are in USD (United States Dollars).

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.

REINSTATEMENT OF COVERAGE FOR INSURED PERSONS:  In the event coverage under this insurance lapses or is terminated in accordance with the PREMIUM and/or TERMINATION OF COVERAGE FOR INSURED PERSONS subparagraphs of the CONDITIONS AND GENERAL PROVISIONS for failure to pay Premium, the Insured Person may apply to the Company for reinstatement (“Reinstatement”).  Reinstatement is at the sole option of the Company, and shall be subject to the Company’s retained right, without obligation or liability of any kind, to reassess and make determination of acceptable risk in its sole and absolute discretion.  In order to be considered for Reinstatement, the Insured Person must submit all of the following to the Company:

(a) a written request for Reinstatement

(b) a newly completed Reinstatement Application, which shall become a part of the Master Policy and any reinstated Certificate

(c) a written statement giving full details, as requested by the Company, of any claims incurred, diagnoses made, manifestations of symptoms or health conditions experienced, and/or Treatment or supplies received by the Insured Person since the Initial Effective Date under this insurance plan

 (d) a written statement giving full details of the reason for the previous failure to pay Premium when due

(e) payment of all Premium due.

If the Company grants Reinstatement, it will promptly notify the Insured Person, and Reinstatement shall be effective as of 12:01 AM, EST, on the date stated in the notice.  If the Company does not grant Reinstatement, the Company's sole obligation and liability shall be to return any paid and unearned Premium to the Insured Person.

RIGHT OF RECOVERY:  In the event of overpayment by the Company of any claim for benefits under this insurance, for any reason, including without limitation because of any of the following:

(a) all or part of the claim was not incurred by or paid by or on behalf of the Insured Person

(b) the Insured Person or any of the Insured Person's Relatives, whether or not the Relative is or was an Insured Person under this insurance plan, is repaid or is entitled to be repaid for all or part of the claim in accordance with the CONDITIONS AND GENERAL PROVISIONS, OTHER INSURANCE provision, for defective equipment or medical devices covered under a warranty, or by or from a source other than the Company

(c) all or part of the claim was not eligible for payment or coverage under the Terms of this insurance

(d) all or part of the claim was paid or reimbursed based on an incorrect or mistaken application of benefits under this insurance

(e) all or part of the claim has been excused, waived, abandoned, forfeited, discounted or released by the provider

(f) the Insured Person is not liable or responsible as a matter of law for all or part of a claim

The Company shall have the right to receive a refund and to recover the amount of overpayment from the Insured Person and/or the Hospital, Physician and/or other provider of services or supplies (as the case may be).  The amount of the refund and recovery for overpayment of claims shall be the difference between: the amount actually paid by the Company; and the amount, if any, that should have been paid by the Company under the Terms of this insurance.

For all other overpayments, the amount of the refund and recovery shall be the amount overpaid

If the Insured Person, Hospital, Physician, or other provider of services or supplies does not promptly make any such refund to the Company, the Company may, in addition to any other rights or remedies available to it (all of which are reserved):

(i) reduce or deduct from the amount of any future claim that is otherwise eligible for coverage or payment under this insurance, to the full extent of the refund due to the Company; and/or

(ii) cancel this Certificate and all further coverage of the Insured Person under the Master Policy by giving thirty (30) days advance written notice by mail to the Insured Person at his/her last known residence or mailing address, and offset against the amount of any refund of Premium due the Insured Person to the full extent of the refund due to the Company

EXPLANATION OR VERIFICATION OF BENEFITS:  In the event of any verbal or telephone inquiry, every attempt will be made to help the Insured Person and his/her healthcare providers and suppliers understand the status, scope and extent of available benefits and coverage under this insurance; provided, however, that no statement made by any agent, employee or representative of the Company or the Plan Administrator will be deemed or construed as an actionable representation, promise, or an estoppel, or will create any liability against the Company or the Plan Administrator or be deemed or construed to bind the Company or to modify, replace, waive, extend or amend any of the Terms of the Master Policy or this Certificate, unless expressly set forth in writing and signed by an authorized agent or representative of the Company.  Actual eligibility determinations, benefit verifications, final coverage decisions, claim adjudications, final payments, reimbursements of benefits, or claims shall be determined and adjudicated only after or at the time a proper and complete Application and/or Proof of Claim is submitted (as the case may be), an opportunity for reasonable investigation and/or review is provided, cooperation required hereunder received, and all facts and supporting information, including relevant data, information and medical records when deemed necessary or appropriate by the Company, are presented in writing.  Appealed claims may be further investigated and/or reviewed.  The Terms of the Master Policy govern all available coverage and payments made or to be made.  If a definite answer to a specific benefits or coverage question is required for any reason, the Insured Person or his/her healthcare providers may submit a written request to the Company, including all pertinent medical information and a statement from the attending Physician (if applicable), and a written reply will be sent by the Company and kept on file.  If the Company elects to verify generally and/or preliminarily to a provider or the Insured Person that an Injury, Illness, diagnosis or proposed Treatment is or may be covered under this insurance, or that benefits for same are or may be available as outlined in this Certificate, any such verification of benefits does not guaranty either payment of benefits or the amount or eligibility of benefits.  Final eligibility determinations, coverage decisions, claim appeals, and actual reimbursement or payment of claims or benefits are subject to all Terms of this insurance, including without limitation filing a proper and complete Proof of Claim and complying with the CONDITIONS AND GENERAL PROVISIONS, COOPERATION provision.

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 his/her 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 the Master Policy and this Certificate, 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, 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 his/her family members or guardians, treating Physicians and other healthcare providers.  If the Insured Person and his/her 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 and the insurance plan shown in the Declaration. Eligibility for and payment of benefits are subject to all of the Terms of this insurance and the insurance plan shown in the Declaration.

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:

(a) Chemotherapy

(b) Extended Care Facility

(c) Home Nursing Care

(d) Inpatient Hospitalization

 (e) Interfacility Ambulance Transfer

 (f) Radiation Therapy

 (g) Surgery or Surgical procedure

 (h) Transplant

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 his/her Physician or healthcare provider must perform all of the following

(a) contact the Company through the Plan Administrator at the telephone numbers printed on the Insured Person’s ID card (contact information below), 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: acm@imglobal.com 

Website: www.imglobal.com/member/precertification

b) comply with the instructions of the Company and submit any information or documents required by the Company

(c) notify all Physicians, Hospitals and other healthcare providers that this insurance contains Pre-certification requirements and ask them to fully cooperate with the Company.

TRANSPLANT PRE-CERTIFICATION REQUIREMENTS:  To comply with the Transplant Pre-certification Requirements, the Insured Person must contact the Company through the Plan Administrator as soon as possible but always within seventy-two (72) hours of becoming a candidate for a Covered Transplant; comply with the instructions of the Company and submit any information or documents required by the Company; and notify all Physicians, Hospitals and other healthcare providers that this insurance contains Pre-certification requirements and ask them to cooperate fully with the Company.

LOSS OF COVERAGE / BENEFITS FOR NON-COMPLIANCE OF PRE-CERTIFICATION REQUIREMENTS:  If the Insured Person or his/her healthcare providers do not comply with the Pre-certification requirements for the Treatment or supplies identified in the SPECIFIC REQUIREMENTS subparagraphs above, other than Covered Transplant Treatment, or if such Treatment or supplies are not Pre-certified:

(a) Eligible Medical Expenses incurred with respect to said Treatment and/or supplies will be reduced by the amount shown in the BENEFIT SUMMARY

(b) the Deductible will be subtracted from the remaining amount

 (c) Coinsurance will be applied.

If the Insured Person or his/her healthcare providers do not comply with the Pre-certification requirements for Treatment or supplies related to Covered Transplant Treatment, or if such Treatment and/or supplies are not Pre-certified, all Transplant Expense benefits shall be forfeited and waived.

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.

SECOND SURGICAL OPINION:  Except in the case of an Emergency, if a Physician recommends a Surgery or Covered Transplant, the Company may require, as a condition to becoming eligible for benefits under this insurance, that the Insured Person consult with another independent Physician for a second opinion as to the Medical Necessity of the Surgery (“Second Surgical Opinion”).

The Insured Person must notify the Company immediately in the event a non-emergency Surgery or Covered Transplant is recommended by a Physician.  The Company will promptly advise the Insured Person whether or not it will require a second opinion.  Upon receipt of a second opinion that differs from the recommending Physician, the Company will promptly advise the Insured Person whether or not it will require a third opinion

(1) The Company will notify the Insured Person if a Second Surgical Opinion is required as soon as is reasonably possible after the Insured Person Pre-certifies such Surgery in accordance with the PRE-CERTIFICATION REQUIREMENTS set forth in this Certificate.

(2) The Physician providing the second opinion must meet all of the following criteria:

(a) not be a Relative of the Insured Person or the first recommending Physician

(b) not be financially or professionally or in any other way associated with the first recommending Physician

(c) provide the Company with a written opinion and any and all documents and records reasonably requested by the Company in support of such opinion.

If the Company does not require a second opinion, the Company will reimburse the Insured Person for Eligible Medical Expenses incurred in accordance with the Terms of this insurance.

If the second opinion is required by the Company, the Company will reimburse the Insured Person for Eligible Medical Expenses incurred for the consultation, including any required diagnostic tests or procedures which were not carried out by the first recommending Physician, without application of any Deductible or Coinsurance.  If the second opinion concurs with the recommending Physician, then the Company will reimburse the Insured Person for Eligible Medical Expenses in accordance with the Terms of this insurance

If the second opinion differs from the recommending Physician, the Insured Person may be required to consult with another Physician for a third opinion as to the Medical Necessity of the Surgery.  The third Physician must also meet the requirements of subparagraphs (a) through (c) immediately above. 

If the third opinion is required by the Company, the Company will reimburse the Insured Person for Eligible Medical Expenses incurred for the consultation, including any required diagnostic tests or procedures which were not carried out by the first or second Physicians, without application of any Deductible or Coinsurance

If the Insured Person is requested or required to obtain a second or third opinion and does not, all benefits otherwise available under this insurance for reimbursement of Eligible Medical Expenses that are directly or indirectly related to or arise as a consequence of the Surgery shall be reduced by fifty percent (50%).

If the Insured Person obtains three (3) opinions, the Company will reimburse the Insured Person for Eligible Medical Expenses incurred in accordance with the Terms of this insurance based on the concurring recommendations of two (2) of the three (3) Physicians’ opinions.  If the Insured Person elects not to follow the recommendations of the two (2) concurring Physicians, all benefits otherwise available under this insurance for reimbursement of Eligible Medical Expenses which are directly or indirectly related to or arise as a consequence of the Surgery, or which are directly or indirectly related to or arise as a consequence of the Insured Person's refusal to undergo the recommended Surgery, shall be reduced by fifty percent (50%).

MEDICAL CONCIERGE SERVICE:  The Medical Concierge Service is a proprietary service of IMG that helps an Insured Person navigate the United States health care system to identify the highest quality providers for scheduled, non-emergency inpatient and certain outpatient treatments.

With Medical Concierge Service, an Insured Person scheduling Inpatient or Outpatient Treatment receives important information to help them choose their medical provider of eligible medical conditions, including information on the cost and quality of hospitals, thereby maximizing the benefits provided under the insurance plan

For non-emergency, Inpatient treatment incurred within the United States, use of the Medical Concierge Service will provide you with a list of qualified providers within the geographical area where you are located when treatment is medically necessary.

Special Benefit when using the Medical Concierge Service:  When you obtain Treatment and incur Eligible Medical Expenses under the insurance plan shown in the Declaration page from a Physician, other health care provider or Hospital chosen by the Insured Person through use of our Medical Concierge Service, irrespective of whether the provider is within the United States preferred provider network (PPO), the Company will adjust the Coinsurance and out-of-pocket expenses to the amount shown in the BENEFIT SUMMARY.

To qualify for these benefits, the Insured Person must contact the Company immediately upon the recommendation by a health care provider that the Insured Person be admitted or receive any of the following:

(1)  Colonoscopy

(2) Computerized Axial Tomography (CAT scans)

(3) Cystoscopy

 (4) Echocardiography

(5) Endoscopy

(6) Gastroscopy

(7) Home nursing care

(8) Inpatient Care in an Extended Care Facility or rehabilitation Facility

 (9) Inpatient status on non-emergency Treatment or Surgery

(10) Magnetic Resonance Imaging (MRI)

(11) Outpatient Surgery

(12) Receiving Covered Transplant Treatment or supplies.

Contact the Company as soon as possible PRIOR to the scheduling of Treatment as follows:

Inside the United States: +1.877.654.6229 Email: mcs@akesocare.com 

Outside the United States: +1.317.655.4500 (Collect if necessary)

 Website: www.imglobal.com/member 

                                                                DEFINITIONS

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.

Adventure Sports:  Activities undertaken for the purposes of recreation, an unusual experience or excitement.  These activities are typically undertaken outdoors and involve a medium degree of risk.

Affidavit of Eligibility:  The properly completed form provided to the Company that certifies that an applicant is eligible to be covered under this insurance plan because they do not meet the citizenship and/or residency requirements of other insurance companies in the area where they reside.

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-contact, 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 form entitled "Application" submitted by or on behalf of the Insured Person for acceptance into, renewal of coverage under, or Reinstatement in this insurance plan.  The 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 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 MutualWealth Management Group, Carmel, IN.

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 Master Policy, and which includes the Insured Person's Application 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 nineteen (19) years of age.

 Class V:  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 V 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:  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 Sirius International Insurance Corporation (publ), headquartered in Stockholm, Sweden.  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:  A physical abnormality, defect or medical condition existing at or before birth, regardless of cause, when diagnosed or treated.

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.

Covered Transplant:  A transplant involving the heart, heart/lung, lung, kidney, kidney/pancreas, liver and allogeneic or autologous bone marrow

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 (and/or upon renewal or Reinstatement hereof) 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 Period of Coverage prior to receiving benefits or coverage under this insurance, and not including any applicable Coinsurance. 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.

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):  Equipment that meets the following criteria: prescribed by a physician; provides therapeutic benefits or enables individuals to perform certain tasks he or she is unable to undertake otherwise due to certain medical conditions or illnesses; can withstand repeated use; is primarily and customarily used to serve a medical purpose; generally is not useful to a person in the absence of an Illness or Injury; and is appropriate for use in the home but may be transported to other locations to allow the individual to complete instrumental activities of daily living, which are more complex tasks required for independent living.

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 date coverage for the Insured Person begins under the Terms of the Master Policy as evidenced by this Certificate, as indicated on the Declaration.

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.

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 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.

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; 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 twentyfour (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, his/her Spouse, and any Child or Children who are covered as an Insured Person under this insurance plan.

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.

 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 Country:  For United States citizens, the Home Country is the United States.  For non- United States citizens, the Home Country is the country of which the Insured Person is a citizen or national; including any country where the Insured Person maintains his/her primary residence or usual place of abode and any country of which the Insured Person is the possessor of a validly issued passport.  In the event there is more than one (1) Home Country under the above-listed criteria, the Home Country is the country meeting the above-listed criteria and listed by the Insured Person as his or her country of residence on the Application.

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:  An institution which operates as a hospice; is licensed by the state or country in which it operates; and operates primarily for the reception, care and palliative control of pain for terminally ill persons who have, as certified by a Physician, a life expectancy of not more than six (6) months

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 Inpatients; provides twenty-four (24) hour nursing service by Registered Nurses on duty or call; has a staff of one or more Physicians available at all times; provides organized Facilities and equipment for diagnosis and Treatment of acute medical, surgical or mental/nervous conditions 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.

Host Country:  The country or countries other than the Home Country that the Insured Person is traveling to or within.

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.

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 the Global Medical 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:  Treatment that includes drugs, procedures, or services that are still in the clinical stages of evaluation and not yet released for distribution by the US Food and Drug Administration.

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.  Local ambulance transport does not include subsequent Interfacility transfers of admitted patients.

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 during the lifetime of the Certificate.  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 his/her 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.

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 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., 2960 North Meridian Street, Indianapolis, Indiana, 46208, 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, 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:  Any Illness, Injury, sickness, disease, or other physical, medical, Mental or Nervous Disorder, condition or ailment that, with reasonable medical certainty, existed at the time of Application or at any time prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all chronic, subsequent or recurring complications or consequences related thereto or resulting or arising therefrom.

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 his or her 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 out 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 diseases 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 his or her name.

Relative:  A parent, legal guardian, spouse, son, daughter, or immediate family member of the Insured Person.

Renewal Premium:  The first Premium payment of each Period of Coverage.  The Renewal Premium does not apply to the first Period of Coverage.

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 his or her personal Injury or Illness.  Self-inflicted specifically includes failure of an Insured Person to follow his or her doctor’s orders, complete prescriptions as directed, or follow any health care protocol or procedures designed to return or maintain his or her health.

Short Rate Cancellation Table:  The table used by the Company to calculate Short Rate Earned Premium in the event of cancellation.  A copy of this table is available to the Insured Person upon request.

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.

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

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:  A phone or video consultation provided by Teladoc Physicians, PA, a network of board-certified providers in the United States available on-demand 24 hours a day, 7 days a week, 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.

Telemedicine:  The use of medical information (beyond a verbal history) exchanged from one healthcare provider site to another via electronic communications to improve patients' health status.  Videoconferencing, transmission of still images, and remote monitoring of vital signs are all considered part of Telemedicine.  Telemedicine services that would be considered for Medical Necessity and appropriateness by the Company under the plan would include without limit:

(a) Specialist referral services which typically involve a specialist assisting a general practitioner in rendering a diagnosis to guide Treatment.

(b) Patient consultations using telecommunications to provide medical data, which may include audio, still or live images, between a patient and a Physician or other healthcare provider for use in rendering a diagnosis and Treatment plan.  This might originate from a remote clinic to a Physician's office using a direct transmission link or may include communicating electronically.

(c) Remote patient monitoring using devices to remotely collect and send data from a medical Facility to a monitoring station for interpretation.  Such applications might include a specific vital sign, such as blood glucose or heart ECG.

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:  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 of the Insured Person’s Home Country, warning that travel to specific identified countries, regions or locations is hazardous and is not advised.

Treated; 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.

Unexpected:  Sudden, unintentional, not expected and unforeseen.

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.

SCHEDULE OF BENEFIT

 

PRE-EXISTING CONDITIONS: Charges relating directly or indirectly to medical conditions existing at the time of Application, whether known or unknown at the time of Application and whether or not disclosed on the Application, are excluded from coverage under this insurance

Home Country: For United States citizens, the Home Country is the United States. For non- United States citizens, the Home Country is the country of which the Insured Person is a citizen or national; including any country where the Insured Person maintains his/her primary residence or usual place of abode and any country of which the Insured Person is the possessor of a validly issued passport. In the event there is more than one (1) Home Country under the above-listed criteria, the Home Country is the country meeting the above-listed criteria and listed by the Insured Person as his or her country of residence on the Application.

Pre-existing Condition: Any Illness, Injury, sickness, disease, or other physical, medical, Mental or Nervous Disorder, condition or ailment that, with reasonable medical certainty, existed at the time of Application or at any time prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all chronic, subsequent or recurring complications or consequences related thereto or resulting or arising therefrom.

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 Charges are Usual, Reasonable and Customary and 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, nursing services, and Ancillary Services not to exceed the average semi-private room rate. A private room will be considered when no semi-private room is available.

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

(c) use of operating, Treatment or recovery room

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

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

(f) Emergency Treatment of an Illness; however charges for use of the emergency room itself within the United States will not be covered 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 the following only when an Inpatient or directly following a related Inpatient stay or Outpatient Surgery:

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

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

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

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

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

(f) reconstructive Surgery when the Surgery is incidental to or follows Surgery which was covered hereunder

(g) radiation therapy or Treatment, and chemotherapy

(h) hemodialysis and the Charges by a Hospital for processing and administration of blood or blood components

(i) oxygen and other gases and their administration

(j) anesthetics and their administration by a Physician

(k) drugs which require 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 post Inpatient Treatment or Outpatient Surgery of any one (1) prescription

(l) 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. Limited to thirty (30) days per Period of Coverage. Home Nursing Care must be recommended by a Physician. Only charges incurred in connection with Home Nursing Care services from the Illness of Injury for which the Insured Person is being treated will be eligible for benefits

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

(i) an Injury

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

(n) 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

(o) 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) Medically Necessary rental of Durable Medical Equipment, up to the purchase price

(q) For Insured Persons with Area 3 coverage only: a Teladoc phone or video consultation with a Physician

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

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

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

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

(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 twentyfour (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 suddenly, Unexpectedly, and spontaneously, and without: (1) advance warning, (2) advance Treatment, diagnosis or recommendation for Treatment by a Physician, or (3) prior manifestation of symptoms or conditions which 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 his/her Home Country at his/her 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 which 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.

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 air 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 period of coverage for the Emergency Reunion shall not exceed fifteen (15) days, including travel days, and all costs and expenses incurred beyond such period of coverage 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 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.

L. HOSPITAL INDEMNITY: Subject to the Terms of this insurance and in the event the Insured Person has been Hospitalized in a Facility outside the United States, during the Period of Coverage, the Company will pay the Insured Person the amount shown in the BENEFIT SUMMARY for each overnight Hospitalization as an Inpatient, so long as the Treatment received during the overnight Hospitalization is considered to be an Eligible Medical Expense.

M. 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 his/her Home Country, 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 his/her Home Country 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.

N. TRANSPLANT: Subject to the Terms of this insurance, the insurance plan shown in the Declaration, and the conditions and restrictions set forth below, 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 with respect to a Covered Transplant obtained or received by the Insured Person while this Certificate is in effect, so long as such costs, Charges or expenses are Usual, Reasonable, and Customary:

(1) Eligible Medical Expenses incurred by a live donor will be treated as if they were the expenses of the Insured Person receiving a Covered Transplant if the Insured Person received an organ or tissue of the live donor

(2) organ procurement and harvesting costs, including donor preparation, excluding acquisition or purchase of the actual organ or tissue, up to the amount shown in the BENEFIT SUMMARY

(3) Charges incurred for pre-transplant evaluation, the Covered Transplant procedure, re-transplantation (if incurred during the initial Hospital confinement as an Inpatient for the Covered Transplant), and post-transplant care

(4) reasonable travel and lodging expenses of the Insured Person if travel of more than fifty (50) miles is necessary to receive the Covered Transplant Treatment and supplies from a Managed Transplant System Network Provider, up to the amount shown in the BENEFIT SUMMARY.

Transplant Pre-certification: To become eligible for Transplant benefits under this insurance, the Transplant must be a Covered Transplant. The Insured Person must receive all Covered Transplant Treatment and supplies from an independent transplant network provider (“Managed Transplant System Network”) approved by the Company through the Plan Administrator and the Covered Transplant must be Pre-certified by the Company in accordance with the Terms of this insurance. If the Insured Person receives Covered Transplant Treatment and supplies from a provider that is not an approved member of the Company’s independent Managed Transplant System Network, or if the transplant is not a Covered Transplant or is not properly Pre-certified, no Transplant benefits shall be available under this insurance. Neither the Company nor the Plan Administrator shall have any right, obligation, or authority of any kind to ultimately select Physicians, Hospitals, or other healthcare providers for the Insured Person or to make any medical Treatment decisions for or on behalf of the Insured Person regarding transplants, and all such decisions shall be made solely and exclusively by the Insured Person and/or his/her family members, treating Physicians, and other healthcare providers. All claims for Transplant benefits are subject to the Terms of this insurance and the insurance plan shown in the BENEFIT SUMMARY.

EXCLUSION

EXCLUSIONS:  Except as expressly provided for in the BENEFIT SUMMARY, all Charges, costs, expenses and/or claims incurred by the Insured Person, and directly or indirectly relating to or arising or resulting from or in connection with any of the following acts, omissions, events, conditions, Charges, consequences, claims, Treatment (including diagnoses, consultations, tests, examinations and evaluations related thereto), services and/or supplies are expressly excluded from coverage under this insurance, and the Company shall provide no benefits or reimbursements and shall have no liability or obligation for any coverage thereof or therefor:

WAR; MILITARY ACTION:  The Company shall not be liable for and will not provide coverage or benefits for any claim or Charges incurred with respect to any Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising or incurred in connection with or as a result of any of the following acts or occurrences:

(a) war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war

(b) mutiny, riot, strike, military or popular uprising, insurrection, rebellion, revolution, military or usurped power

 (c) any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by violence of any type

(d) martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege

 (e) any use of radiological, chemical, nuclear or biological weapons or any other radiological, chemical, nuclear or biological events of any type (including in connection with an act of Terrorism).

Any claim, Charges, Illness, Injury or other consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether or not directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said occurrences shall be deemed and considered to be consequences for which the Company shall not be liable under the Master Policy or this Certificate, except to the extent that the Insured Person shall prove that such claim, Charges, Illness, Injury or other consequence happened independently of the existence of such abnormal conditions and/or occurrences.

TERRORISM:  The Company shall not be liable for and will not provide coverage or benefits for any claim or charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with any act of Terrorism.  Further, the Company shall not be liable for and will not provide any coverage or benefits for any claim, charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with the following:

(a) the Insured Person’s active and voluntary planning or coordination of or participation in any act of Terrorism

(b) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning was issued or in effect on or within six (6) months prior to the Insured Person’s date of arrival in said location, post, area, territory or country

(c) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning becomes effective or is in effect on or after the Insured Person’s date of arrival in said location, post, area, territory or country, and the Insured Person unreasonably fails or refuses to heed such warning and thereafter remains in said location, post, area, territory or country.

PRE-EXISTING CONDITIONS:  Charges relating directly or indirectly to medical conditions existing at the time of Application, whether known or unknown at the time of Application and whether or not disclosed on the Application, are excluded from coverage under this insurance.

ILLNESS OR SURGERY WITHIN 180 DAYS:  Charges for Treatment of the following Illnesses or Surgeries which manifest themselves and/or involve procedures which take place and/or are recommended during the first one-hundred eighty (180) days of coverage under this insurance plan, beginning on the Initial Effective Date: acne, asthma, allergies, any condition of the breast, any condition of the prostate, tonsillectomy, adenoidectomy, hemorrhoids or hemorrhoidectomy, disorders of the reproductive system,  diverticulitis, hysterectomy, hernia, intervertebral disc disease, gall bladder disease or gall stones and kidney stones.  Note: Coverage and/or benefits for these Illnesses or Surgeries (or for similar or different Illnesses or Surgeries) may be separately or further limited.

MATERNITY AND NEWBORN CARE:  Charges for pre-natal care, delivery, post-natal care, and care of Newborns, including complications of Pregnancy, miscarriage, complications of delivery and/or of Newborns are excluded from this insurance

MENTAL OR NERVOUS DISORDERS:  Charges for Treatment of Mental or Nervous Disorders are excluded from this insurance.

PREVENTATIVE CARE:  Charges for Routine Physical Examinations and immunizations are excluded from coverage under this insurance.

Charges for any Treatment or supplies that are:

(a) not incurred, obtained or received by an Insured Person during the Period of Coverage

(b) not presented to the Company for payment by way of a complete Proof of Claim within ninety (90) days of the date such Charges are incurred

(c) not administered or ordered by a Physician

d) not Medically Necessary for the diagnosis, care or Treatment of the physical condition involved. This also applies when and if they are prescribed, recommended or approved by the attending Physician

(e) provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable

(f) in excess of Usual, Reasonable, and Customary

 (g) related to Hospice Care

(h) incurred by an Insured Person who was HIV + on or before the Initial Effective Date of this insurance, whether or not the Insured Person had knowledge of his/her HIV status prior to the Effective Date, and whether or not the Charges are incurred in relation to or as a result of said status.  This exclusion includes charges for any Treatment or supplies relating to or arising or resulting directly or indirectly from HIV, AIDS virus, AIDS related Illness, ARC Syndrome, AIDS and/or any other Illness arising or resulting from any complications or consequences of any of the foregoing conditions

 (i) provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician

 (j) performed or provided by a Relative of the Insured Person

 (k) not expressly included in the ELIGIBLE MEDICAL EXPENSES provision

(l) provided by a person who resides or has resided with the Insured Person or in the Insured Person's home

(m) required or recommended as a result of complications or consequences arising from or related to any Treatment, Illness, Injury, or supply excluded from coverage or which is otherwise not covered under this insurance

(n) for Congenital Disorders and conditions arising out of or resulting there from

(9) Except as incurred using Teladoc, Telemedicine consultations through an established Telemedicine protocol system will be considered individually based on medical necessity and appropriateness as determined by the Company under the plan

(10) Charges incurred for failure to keep a scheduled appointment

(11) Charges incurred for Surgeries, Treatment or supplies which are Investigational, Experimental, and for research purposes

(12) Charges incurred related to genetic medicine, genetic testing, surveillance testing and/or wellness screening procedures for genetically predisposed conditions indicated by genetic medicine or genetic testing, including, but not limited to amniocentesis, genetic screening, risk assessment, preventive and prophylactic surgeries recommended by genetic testing, and/or any procedures used to determine genetic pre-disposition, provide genetic counseling, or administration of gene therapy

 (13) Charges incurred for testing that attempts to measure aspects of an Insured Person’s mental ability, intelligence, aptitude, personality and stress management.  Such testing may include but is not limited to psychometric, behavioral and educational testing

 (14) Charges incurred for Custodial Care

(15) Charges incurred for Educational or Rehabilitative Care that specifically relates to training or retraining an Insured Person to function in a normal or near-normal manner.  Such care may include but is not limited to job or vocational training, counseling, occupational therapy and speech therapy

(16) Charges for weight modification or any Inpatient, Outpatient, Surgical or other Treatment of obesity (including without limitation morbid obesity), including without limitation wiring of the teeth and all forms or procedures of bariatric Surgery by whatever name called, or reversal thereof, including without limitation intestinal bypass, gastric bypass, gastric banding, vertical banded gastroplasty, biliopancreatic diversion, duodenal switch, or stomach reduction or stapling

(17) Charges for modification of the physical body in order to change or improve or attempt to change or improve the physical appearance or psychological, mental or emotional well-being of the Insured Person (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof)

(18) Charges or Treatment for cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and/or follows a Surgery which was covered under this insurance

(19) elective Surgery or Treatment of any kind

(20) Charges incurred for any Treatment or supply that either promotes or prevents or attempts to promote or prevent conception, insemination (natural or otherwise) or birth, including but not limited to: artificial insemination; oral contraceptives; Treatment for infertility or impotency; vasectomy, or reversal of vasectomy; sterilization; reversal of sterilization; surrogacy or abortion

(21) Charges incurred for any Treatment or supply that either promotes, enhances or corrects or attempts to promote, enhance or correct impotency or sexual dysfunction

(22) any Illness or Injury sustained while taking part in, practicing or training for: Amateur Athletics; Professional Athletics; or athletic activities that are sponsored by any Governing Body or Authority including the National Collegiate Athletic Association, any other collegiate sanctioning or Governing Body or the International Olympic Committee

(23) any Illness or Injury sustained while taking part in activities designated as Adventure Sports, which are limited to the following: abseiling; BMX; bobsledding; bungee jumping; canyoning; caving; hot air ballooning; jungle zip lining; parachuting; paragliding; parascending; rappelling; skydiving; spelunking; whitewater kayaking or whitewater rafting in water less than Class V difficulty; wildlife safaris; and windsurfing

(24) any Illness or Injury sustained while taking part in activities designated as Extreme Sports, which include but are in no way limited to the following (and include any combination or derivative of the following): BASE jumping; cave diving; cliff diving; downhill mountain biking and racing; extreme skiing; freediving; free flying; free running; free skiing; freestyle scootering; gliding; heli-skiing; ice canoeing; ice climbing; kitesurfing; mixed martial arts; motocross; motorcycle racing; motor rally; mountaineering above elevation of 4500 meters from ground level; parkour; piloting a commercial or non-commercial aircraft; powerbocking; scuba diving or sub aqua pursuits below a depth of 50 meters; snowmobile racing; truck racing; whitewater kayaking or whitewater rafting Class V and higher difficulty; and wingsuit flying

(25) any Illness or Injury sustained while taking part in snow skiing, snowboarding or snowmobiling where the Insured Person is in violation of applicable laws, rules or regulations of a ski resort, including backcountry skiing, off-piste, out of bounds or in unmarked or unpatrolled areas

(26) any Illness or Injury sustained while taking part in athletic or recreational activities where the Insured Person is not physically or medically fit or does not hold the necessary qualifications to engage in said activities

(27) any Illness or Injury sustained while taking part in Collision Sports

(28) any Illness or Injury sustained while participating in any sporting, recreational or adventure activity where such activity is undertaken against the advice or direction of any local authority or any qualified instructor or contrary to the rules, recommendations and procedures of a recognized governing body for the sport or activity

(29) any Illness or Injury sustained while participating in any activity where such activity is undertaken in disregard of or against the recommendations, Treatment programs, or medical advice of a Physician or other healthcare provider

(30) any Injury or Illness sustained as a result of being under the influence of or due wholly or partly to the effects of alcohol, liquor, intoxicating substance, narcotics or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician but not for the Treatment of Substance Abuse

(31) any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs in excess of the applicable blood/alcohol legal limit, other than drugs taken in accordance with Treatment prescribed and directed by a Physician.  For purposes of this exclusion, “vehicle” shall include motorized devices regardless of whether or not a driver or operator license is required (including watercraft and aircraft) and non-motorized bicycles and scooters for which no permit or license is required

(32) any willfully Self-inflicted Injury or Illness

 (33) any sexually transmitted or venereal disease

(34) any testing for the following when not Medically Necessary: HIV, seropositivity to the AIDS virus, AIDS related Illnesses, ARC Syndrome, AIDS

 (35) any Illness or Injury resulting from or occurring during the commission of a violation of law by the Insured Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations

(36) any Substance Abuse

 (37) biofeedback, recreational, sleep or music therapy (38) orthoptics, visual therapy or visual eye training

(39) any non-surgical Illness or Treatment of the feet, including without limitation: orthopedic shoes; orthopedic prescription devices to be attached to or placed in shoes; Treatment of weak, strained, flat, unstable or unbalanced feet; metatarsalgia, bone spurs, hammer toes or bunions; and any Treatment or supplies for corns, calluses or toenails; except as otherwise expressly set forth

(40) hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician

 (41) any sleep disorder, including without limitation sleep apnea

 (42) any exercise and/or fitness program or equipment, whether or not prescribed or recommended by a Physician

 (43) any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s)

 (44) any organ or tissue or other transplant or related services, Treatment or supplies except as otherwise expressly set forth

 (45) any artificial or mechanical devices designed to replace human organs temporarily or permanently after termination of Inpatient status

 (46) any transplant expenses incurred outside the Company’s approved independent Managed Transplant System Network

(47) any efforts to keep a donor alive for a transplant procedure

(48) any Covered Transplant in excess of one (1) during any twelve (12) month period of coverage under this insurance plan, except re-transplantation Charges if incurred during the initial Covered Transplant Hospitalization

 (49) Any Illness or Injury incurred in the Host Country 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 the Insured Person’s entry into the Host Country, any of the following were issued regarding the Host Country (a) the World Health Organization had issued an Emergency Travel Advisory (b) the United States Centers for Disease Control & Prevention had issued a Warning Level 3 (avoid nonessential travel) (c) a similar governmental agency of the Insured Person’s Home Country had published, communicated or issued a Travel Warning restriction or official declaration informing the public about such health issues before the Insured Person traveled to the Host Country

 (50) Charges incurred for eyeglasses, contact lenses, hearing aids or hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason

(51) Charges incurred for eye Surgery, such as but not limited to radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness, or astigmatism

(52) Charges incurred for Treatment or supplies for temporomandibular joint (TMJ) including but not limited to TMJ syndrome, craniomandibular syndrome, chronic TMJ pain, orthognathic Surgery, Le-Fort Surgery or splints

(53) Charges incurred by the Insured Person for the Treatment of his/her Newborns (or for supplies related thereto)

(54) Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance

(55) Except as otherwise expressly provided for in this insurance, Charges or expenses incurred for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; drugs or medicines not approved by the U.S. Food and Drug Administration or which are considered “off-label” drug use; and for drugs or medicines not prescribed by a Physician

(56) Charges incurred for Dental Treatment, except as specifically provided for hereunder

 (57) Wear and tear of teeth due to cavities and chewing or biting down on hard objects, such as but not limited to pencils, ice cubes, nuts, popcorn, and hard candies

 (58) Dental Injury without associated face, skull, neck and/or jaws Injury or that can be evaluated and treated in a dental office

PRE-EXISTING CONDITIONS:  Charges relating directly or indirectly to medical conditions existing at the time of Application, whether known or unknown at the time of Application and whether or not disclosed on the Application, are excluded from coverage under this insurance.

Pre-existing Condition:  Any Illness, Injury, sickness, disease, or other physical, medical, Mental or Nervous Disorder, condition or ailment that, with reasonable medical certainty, existed at the time of Application or at any time prior to the Effective Date of this insurance, whether or not previously manifested, symptomatic or known, diagnosed, Treated, or disclosed to the Company prior to the Effective Date, and including any and all chronic, subsequent or recurring complications or consequences related thereto or resulting or arising therefrom.

UNITED STATES PREFERRED PROVIDER ORGANIZATION (PPO)

SPECIAL BENEFITS:  If Treatment or supplies eligible for coverage under this insurance are received directly from the Company’s approved list of independent Preferred Provider Organization (PPO) providers while the Insured Person is in the United States, the Company will adjust the Deductible and/or Coinsurance applicable to such claims according to the amount shown in the BENEFIT SUMMARY.  However, all claims for Treatment or supplies received in the United States from a non-PPO provider will remain subject to the applicable Deductible and Coinsurance, whether or not the Insured Person may be eligible for the foregoing special benefit relating to Treatment or supplies received from PPO providers.

PPO INFORMATION:  The Company, through the Plan Administrator, endeavors to maintain a contractual arrangement with one (1) or more independent Preferred Provider Organizations (PPO) that has established and maintains a network of United States-based Physicians, Hospitals and other healthcare and health service providers who are contracted separately and directly with the PPO and who may provide re-pricings, discounts or reduced Charges for Treatment or supplies provided to the Insured Person.  Neither the Company nor the Plan Administrator has any authority or control over the operations or business of the PPO, or over the operations or business of any provider within the independent PPO network.  Neither the PPO nor provider within the PPO network, nor any of their respective agents, employees or representatives has or shall have any power or authority whatsoever to act for or on behalf of the Company or the Plan Administrator in any respect, including without limitation no power or authority to perform any of the following:

(a) approve Applications or enrollments for initial, renewal or reinstated coverage under this insurance plan or to accept Premium payments

(b) accept risks for or on behalf of the Company

(c) act for, speak for or bind the Company or the Plan Administrator in any way

(d) waive, alter or amend any of the Terms of the Master Policy or this Certificate, or waive, release, compromise or settle any of the Company’s rights, remedies or interests thereunder or hereunder

(e) determine Pre-certification, coverage eligibility or verification of benefits, or make any coverage, benefit or claim adjudications or decisions of any kind.

It is not a requirement of this insurance that the Insured Person seek Treatment or supplies exclusively from a provider within the independent PPO network.  However, the Insured Person’s use or non-use of the PPO network may affect the scope and extent of benefits available under this insurance, including without limitation any applicable Deductible, Coinsurance and benefit reduction, as set forth above.

An Insured Person may contact the Company through the Plan Administrator and request a PPO directory for the area where the Insured Person will be receiving consultation or Treatment (therein listing the Physicians, Hospitals and other healthcare providers within the PPO network by location and specialty), or an Insured Person may visit the Plan Administrator’s website at www.imglobal.com/member to obtain such information.

 

Renewal of Coverage

RENEWAL; AMENDMENTS:  Subject to the Terms of the TERMINATION OF MASTER POLICY, TERMINATION OF COVERAGE FOR INSURED PERSONS, and REINSTATEMENT OF COVERAGE FOR INSURED PERSONS subparagraphs of the CONDITIONS AND GENERAL PROVISIONS, coverage under the insurance plan will be automatically renewed on each anniversary of the Insured Person’s first day of coverage for an additional duration identical to the original Period of Coverage or twelve (12) months, whichever is shorter.  Renewal is subject to the Terms of the plan then in effect (including the Terms of the then applicable Master Policy) and so long as renewal Premium is paid when due or within the allowable grace period and the Insured Person otherwise continues to meet the applicable eligibility requirements of the plan. Coverage under the insurance plan will not automatically renew if and only if:

(a) the Company provides thirty (30) days written notice to the Insured Person prior to the expiration date of the then existing Period of Coverage; or

(b) the Insured Person has cancelled the policy in accordance with the CONDITIONS AND GENERAL PROVISIONS, CANCELLATION BY INSURED PERSON provision.

The Company reserves the right in its sole discretion to make changes, additions and/or deletions to the Terms of the Master Policy, this Certificate, renewals or replacements of either, and/or to the insurance plan (including the issuance of Riders to effectuate same) at any time or from time to time after the Effective Date of Coverage of this Certificate, upon no less than thirty (30) days prior written notice to the Assured and the Insured Person (“Notice of Amendment”).  The Notice of Amendment shall include a complete description of the changes, additions and/or deletions to be made, the effective date thereof (the “Change Date”), and notice of the Insured Person’s cancellation rights as set forth below, and shall be sent electronically or first class mail, postage pre-paid, to the last known residence or mailing address of the Insured Person.  Upon issuance of the Notice of Amendment, the Assured and/or the Insured Person shall have the right to request cancellation of this Certificate above, at any time prior to the Change Date; provided, however that cancellation under this provision shall be at the option of the Insured Person, and coverage under this insurance shall terminate with effect from the cancellation date specified by the Insured Person (subject to the provisions of the CONDITIONS AND GENERAL PROVISIONS, TERMINATION OF COVERAGE FOR INSURED PERSONS).  If the Insured Person does not elect to cancel this Certificate in accordance with the foregoing, the changes, additions and/or deletions as made by the Company and specified in said Notice of Amendment shall take effect as of the Change Date specified in the Company’s Notice, and this insurance shall thereafter continue in effect in accordance with its Terms, as so amended and modified.

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