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:

  1. be a Full-Time Student or Scholar, the Spouse of the Full-Time Student or Scholar, or a Dependent traveling with the Full-Time Student or Scholar, and residing outside their Home Country for the purpose of pursing international educational activities including, but not limited to college course work, research, or teaching for a temporary period of time; and
  2. at the time of the Effective Date, be physically residing in Host Country with the intent to reside there for at least thirty days; and
  3. 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; and
  4. pay the required Premium on or before the Effective Date of Coverage; and
  5. receive written acceptance of his/her Application or renewal from the Company; and
  6. be at least thirty one (31) days old but not yet sixty-five (65) years old; and
  7. not be Hospitalized or Disabled on the Initial Effective Date; and
  8. not be HIV+ on the Initial Effective Date.

Coverage Limit / Maximum Amount for Eligible Medical Expenses
Period of Coverage Maximum Limit: 365 days
Maximum Limit
Insured Person: $1,000,000 Spouse and Child: $100,000
Maximum Limit per Illness or Injury
Insured Person: $500,000 Spouse and Child: $100,000
Area of Coverage Worldwide excluding Insured Person’s Country of Residence
Benefit Plan Features
Benefit Levels
United States United States International
In-Network Out-of-Network International
Deductible for Eligible Medical Expenses
Deductible
  • Per Illness or Injury
$25 $50 $25
Coinsurance for Eligible Medical Expenses
Coinsurance
  • In addition to Deductible
Plan pays 100%
Insured pays 0%
Plan pays 80%
Insured pays 20%
Plan pays 100%
Insured pays 0%
Out of Pocket Maximum
$0 $1,000 $0
Student Health Center
Copayment per visit
  • Not subject to Deductible
$5
Coinsurance Plan pays 100%
Insured pays 0%
Pre-certification
  • Interfacility Ambulance Transfer: No coverage if Pre-certification requirements are not met.
  • Medical Evacuation: No coverage if not approved by the Company. Refer to the EMERGENCY MEDICAL EVACUATION provision for complete requirements and coverage.
  • Maternity: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
  • All other Treatments & supplies: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
  • Deductible is taken after reduction.
  • Coinsurance is applied to remainder of the reduced amount.
  • Refer to PRE-CERTIFICATION REQUIREMENTS provision for a complete list of services that require Pre-certification.
Pre-existing Conditions
Charges are excluded until the Insured Person has maintained 6 months of continuous coverage under this insurance.
Inpatient or Outpatient Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Benefit In-Network Out-of-Network International
Physician Visits / Services
  • Maximum Visits per Day: 1
  • Surgery is not subject to the maximum visit limit
100% 80% 100%
Hospital Emergency Room
  • Injury: Not subject to Emergency Room Deductible
  • Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission.
100% 80% 100%
Hospitalization / Room & Board
  • Average semi-private room rate
  • Includes nursing, miscellaneous and Ancillary Services
100% 80% 100%
Intensive Care 100% 80% 100%
Outpatient Surgical / Hospital Facility 100% 80% 100%
Laboratory 100% 80% 100%
Radiology / X-ray 100% 80% 100%
Chemotherapy / Radiation Therapy 100% 80% 100%
Pre-admission Testing 100% 80% 100%
Surgery 100% 80% 100%
Reconstructive Surgery
  • Surgery is incidental to or follows Surgery that was covered under the Plan
100% 80% 100%
Assistant Surgeon
  • 20% of the primary surgeon’s eligible fee
100% 80% 100%
Anesthesia 100% 80% 100%
Durable Medical Equipment 100% 80% 100%
Chiropractic Care
  • Medical order or Treatment plan required
100% 80% 100%
Physical Therapy
  • Maximum Visits per Day: 1
  • Medical order or Treatment plan required
100% 80% 100%
Maternity and Newborn Care
  • Maximum Limit: $5,000
  • Newborn routine care during the first 31 days of life
80% 60% 100%
Extended Care Facility
  • Upon direct transfer from acute care Hospital
100% 80% 100%
Inpatient or Outpatient Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Benefit In-Network Out-of-Network International
Home Nursing Care
  • Provided by a Home Health Care Agency
  • Upon direct transfer from an acute care Hospital
100% 80% 100%
Prescriptions
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Inpatient 100% 80% 100%
Outpatient Not Applicable 50% 50%
Mental or Nervous / Substance Abuse
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Inpatient Mental or Nervous / Substance Abuse
  • Maximum Limit: $10,000
  • Not covered if incurred at the Student Health Center
100% 80% 100%
Outpatient Mental or Nervous / Substance Abuse
  • Maximum Limit per Day: $50
  • Maximum Limit: $500
  • Not covered if incurred at the Student Health Center
100% 80% 100%
Emergency Services
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Emergency Local Ambulance
  • Period of Coverage Limit per Injury: $750
  • Period of Coverage Limit per Illness $750
(resulting in an Inpatient Hospitalization)
100% 100% 100%
Emergency Medical Evacuation
  • Maximum Limit: $500,000
  • Must be approved in advance and coordinated by the Company
100% 100% 100%
Emergency Reunion
  • Maximum Limit: $50,000
  • Maximum Days: 15
  • Meal Maximum per Day: $25
  • Reasonable and necessary travel costs and accommodations
  • Must be approved in advance by the Company
100% 100% 100%
Emergency Services
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Benefit In-Network Out-of-Network International
Interfacility Ambulance Transfer
  • Services rendered in the United States
  • Transfer must be a result of an Inpatient Hospitalization
100% 100% Not Applicable
Political Evacuation and Repatriation
  • Maximum Limit: $10,000
  • Must be approved in advance by the Company
100% 100% 100%
Return of Mortal Remains
  • Maximum Limit: $50,000
  • Local Burial / Cremation at place of death
    • Maximum Limit: $5,000
  • Return of Insured Person’s Mortal Remains to Country of Residence
  • Must be approved in advance by the Company
100% 100% 100%
Other Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Accidental Death & Dismemberment
  • Not subject to Deductible and Coinsurance
  • Death must occur within 90 days of the Accident
Accidental Death Principal Sum:
Insured Person
Spouse
Child

$25,000
$10,000
$5,000
Accidental Dismemberment:
Loss
Sight of one eye
One hand or one foot
One hand and the loss of sight of one eye
One foot and the loss of sight of one eye
One hand and one foot
Both hands or both feet
Sight of both eyes

Percent of Principal Sum
50%
50%
100%
100%
100%
100%
100%
Dental Treatment
  • Period of Coverage Limit: $350 (Treatment due to Unexpected pain to sound, natural teeth)
  • Period of Coverage Limit per Injury: $500 (Non-emergency Treatment by a Dental Provider due to an Accident)
Not Applicable 80% 100%
Other Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable and Customary
Limits per Period of Coverage unless stated as Maximum Limit
Benefit In-Network Out-of-Network International
Traumatic Dental Injury
  • Treatment at a Hospital Facility due to an Accident
  • Additional Treatment for the same Injury rendered by a Dental Provider will be paid at 100%
100% 80% 100%
Incidental Trip
  • Maximum Days: 14
  • Insured Person’s Country of Residence is not the United States
  • Refer to the INCIDENTAL TRIP provision for further details
100% 80% 100%
Intercollegiate, Interscholastic, Intramural, or Club Sports
  • Period of Coverage Limit per Illness or Injury: $5,000
100% 80% 100%
Personal Liability
  • Secondary to any other insurance
  • No coverage for Injury to a related Third Party or damage to related Third Person’s property
  • Refer to the PERSONAL LIABILITY provision for further details and requirements
Combined Maximum Limit: $10,000
Injury to Third Person:
  • Per Injury Deductible: $100

Damage to Third Person’s property:
  • Per damage Deductible: $100
Terrorism
  • Not subject to Deductible and Coinsurance
  • Maximum Limit: $50,000
100% 100% 100%

Except as expressly provided for in the BENEFIT SUMMARY, all Charges, costs, expenses and/or claims incurred by the Insured Person, and any claim for death or dismemberment benefits, 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:

Pre-Existing Condition Rider(Platinum Plan Only):

Charges excluded until after 6 months of continuous coverage

The Maternity & Pre-Existing Condition Rider is available for eligible participants. Under this rider, eligible medical expenses for pre-natal care, delivery, post-natal care, and care of newborns can be covered after the insured has maintained coverage continuously for 10 months and the pregnancy is a result of natural insemination. Eligible medical expenses relating to a pre-existing condition can be covered after the insured has maintained coverage continuously for 6 months.

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

Subject to the Terms of the Termination of Master Policy and Termination of Coverage for Insured Persons sections, an Insured Person whose initial Period of Coverage is at least three (3) months can request coverage under this insurance plan to be renewed a minimum of five (5) days until reaching  a maximum of sixty (60) continuous months in accordance with and 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 and the Insured Person otherwise continues to meet the applicable eligibility requirements of the plan.

The Company’s commitment and the Insured Person’s ability to renew is also subject to termination upon thirty (30) days written notice to the other party prior to the expiration date of the then existing Period of Coverage. 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 ninety (90) 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 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 section 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 Termination of Coverage for Insured Persons section. 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.

The Insured Person shall have five (5) days from the Initial Effective Date of Coverage (the “Review Period”) to review the benefits, conditions, limitations, exclusions and all other Terms of the Master Policy as evidenced and outlined by this Certificate. If not completely satisfied, the Insured Person may request cancellation of this insurance retroactive to the Initial Effective Date of Coverage by sending a written request to the Company by email, mail or fax and received by the Company within the Review Period, thereby qualifying to receive a full refund of Premium paid. Upon effectuation of such cancellation and refund, neither the Company nor the Insured Person shall have any further rights, liabilities or obligations under this insurance. After the Review Period, the following conditions apply if the Insured Person wishes to cancel this insurance:

(a) If any claims have been filed with the Company, the Premium is fully earned and is non-refundable.
(b) If no claims have been filed with the Company:

(i) a cancellation fee of fifty dollars ($50.00 USD) will be charged; and
(ii) only Premium covering time periods after cancellation are refundable; and
(iii) only full month Premiums are refundable.

Before Policy Effective Date: Full Refund
After Policy Effective Date (if no claim filed): Unused Portion of Premium (Full Remaining Months Only) - $50 Cancellation Fee

Please send cancellation request at: cancel@imglobal.com and copy that email to us. Our email is given on Contact Us page.

PROOF OF CLAIM

When the Company receives notice of a claim for benefits under this insurance from or on behalf of an Insured Person it will provide the Insured Person with Claimant’s Statement and Authorization Forms (“Claim Forms”) for filing Proof of Claim. The following items must be submitted by or on behalf of the Insured Person to be considered a complete Proof of Claim eligible for consideration of coverage under this insurance (“Proof of Claim”):

  1. a duly completed, timely submitted, and signed Claim Form and authorization for release of information; and
  2. all original itemized bills and statements of services rendered from all Physicians, Hospitals and other healthcare or medical service providers involved with respect to the claim; and
  3. all original receipts for any costs, fees or expenses that have been incurred or paid by or on behalf of the Insured Person with respect to the claim, including without limitation all original receipts for any cash and/or credit card payments.

The Insured Person and/or Physician, Hospital and other healthcare and medical service providers and suppliers shall have ninety (90) days from the date a claim is incurred to submit a complete Proof of Claim, and the Company at its option may pend resolution and adjudication of submitted claims and/or may deny coverage: for Proofs of Claim submitted thereafter; or for incomplete Proofs of Claim; and/or for failure to submit a Proof of Claim; provided, however, that the Company at its option may waive the requirements regarding submission of a new Claim Form for subsequent claims incurred by an Insured Person relating to a continuing Illness, Injury or other medical condition for which a properly completed and signed Claim Form has previously been submitted and received.

APPEALING A CLAIM

In the event the Company denies all or part of a claim, the Insured Person shall have a maximum of two mandatory appeal levels to appeal the denial under which there will be a review of the claim and the determination. Insured Persons shall have sixty (60) days from the date that the notice of denial was mailed to the Insured Person's last known residence or mailing address within which to appeal the determination, and shall have the opportunity to submit written comments, documents, records, and other information relating to the claim. The Company’s review will take into account all comments, documents, records, and other information submitted by the Insured Person relating to the claim, without regard to whether such information was submitted or considered in the initial claim determination. Insured Persons must file two (2) appeals of a claim denial prior to bringing any legal action under the contract of insurance. Upon receipt of a written appeal, the Company shall have an opportunity for further reasonable investigation and/or review as set forth in the Explanation or Verification of Benefits section, and will respond in writing as soon as reasonably practicable, and in any event within ninety (90) days from receipt thereof.