Atlas Group America
U.S. Citizens and Non-U.S. Citizens who are at least 14 days of age and traveling with a group of at least five (5) members are eligible for coverage outside of their home countries, except as provided under home country coverage. U.S. Citizens and residents are not eligible for coverage within the U.S, except as provided under home country coverage or an eligible benefit period. Individuals age 70 to 79 as of the certificate effective date are subject to a $100,000 overall maximum limit or less. Individuals age 80 and over as of the certificate effective date are subject to a $10,000 overall maximum limit.
Except as specifically indicated otherwise, all benefits are subject to deductible, coinsurance, and are per certificate period.
|Overall Maximum Limit (Excludes Emergency Medical Evacuation, Accidental Death and Dismemberment, Common Carrier Accidental Death, Personal Liability, and Crisis Response)||Age 80 or older $10,000. Age 70 to 79: $50,000, $100,000. All others: $50,000, $100,000, $200,000, $500,000,or $1,000,000|
|Maximum per Injury / Illness||Age 80 or older $10,000. Age 70 to 79: $50,000, $100,000. All others: $50,000, $100,000, $200,000, $500,000, or $1,000,000|
|Deductibles||$0, $100, $250, $500, $1,000 or $2,500 per certificate period|
|Coinsurance – Claims incurred in U.S. or Canada||We will pay 80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum limit. Coinsurance will be waived if expenses are incurred within the Preferred Provider Organization (PPO).|
|Coinsurance – Claims incurred outside U.S. or Canada||We will pay 100% of eligible expenses after the deductible up to the overall maximum limit.|
|Subject To Deductible, Coinsurance, and per Certificate Period unless specifically indicated otherwise|
|Hospital Room and Board||Average semi-private room rate, including nursing services|
|Intensive Care Unit||Usual, reasonable and customary charges|
|Local Ambulance||Usual, reasonable and customary charges, when covered illness or injury results in hospitalization as inpatient.|
|Emergency Room Co-payment – Claims incurred in U.S. or Canada||You shall be responsible for a $200 co-payment for each use of emergency room for an illness unless you are admitted to the hospital. There will be no co-payment for emergency room treatment of an injury.|
|Urgent Care Center – Claims incurred in U.S. or Canada||Claims incurred in U.S.
For each visit, you shall be responsible for a $15 co-payment, after
which coinsurance will apply.
– Co-payment is waived for members with a $0 deductible.
– not subject to deductible
|Acute Onset of Pre-existing Condition (excludes chronic and congenital conditions) (only available to members under age 70)||Overall maximum limit
$25,000 lifetime maximum for Emergency Medical Evacuation
|Terrorism||$50,000 lifetime maximum, eligible medical expenses only.|
|Physical Therapy and Chiropractic Care||$50 maximum per day. Must be ordered in advance by a physician.|
|All Other Eligible Medical Expenses||Usual, reasonable and customary charges|
|Not Subject to Deductible or Coinsurance|
|Emergency Medical Evacuation||$1,000,000 lifetime maximum, except as provided under Acute Onset of Pre-existing Condition|
|Repatriation of Remains||Overall maximum limit|
|Local Burial or Cremation||$5,000 lifetime maximum|
|Crisis Response- Ransom, Personal Belongings, and Crisis Response Fees and Expenses||$10,000|
|Optional Crisis Response Rider with Natural Disaster Evacuation||$90,000 per certificate period, with $10,000 maximum for Natural Disaster Evacuation|
|Emergency Reunion||$50,000, subject to a maximum of 15 days|
|Return of Minor Children||$50,000|
|Political Evacuation||$10,000 lifetime maximum|
|Accidental Death & Dismemberment (excludes loss due to Common Carrier Accident)|
|Ages 18 through 69||Lifetime Maximum - $50,000
Death - $50,000
Loss of 2 Limbs - $50,000
Loss of 1 Limb - $25,000
|Under age 18||Lifetime Maximum - $5,000
Death - $5,000
Loss of 2 Limbs - $5,000
Loss of 1 Limb - $2,500
|Ages 70 through 74||Lifetime Maximum - $12,500
Death - $12,500
Loss of 2 Limbs - $12,500
Loss of 1 Limb - $6,250
|Ages 75 and older||Lifetime Maximum - $6,250
Death - $6,250
Loss of 2 Limbs - $6,250
Loss of 1 Limb - $3,125
$250,000 maximum benefit any one family or group.
|Optional Accidental Death & Dismemberment Rider (only available to members age 18 through age 69)||Lifetime Maximum - $50,000
Death - $50,000
Loss of 2 Limbs - $50,000
Loss of 1 Limb - $25,000
|Common Carrier Accidental Death
Ages 18 through 69
Under age 18
Ages 70 through 74
Ages 75 and older
Subject to a maximum of $250,000 any one family or group.
|Lost Checked Luggage||$500|
|Travel Delay||Maximum $100 a day after a 12-hour delay period requiring an unplanned overnight stay. Subject to a maximum of 2 days.|
|Emergency Dental (Acute Onset of Pain)||$250|
|Natural Disaster - Replacement Accommodations||Maximum $100 a day for 5 days|
|Hospital Indemnity||$100 per day of inpatient hospitalization|
|Personal Liability||$10,000 lifetime maximum
$10,000 third person injury
$10,000 third person property
$2,500 related third person property
|Optional Personal Liability Rider||$90,000 lifetime maximum|
Excluded Conditions, Treatments (includes Diagnoses, Tests, and Examinations), Services, Supplies, Acts, Omissions, and/or Events:
- Pre-existing Conditions, except charges resulting directly from an Acute Onset of Pre-existing Condition, as herein defined, subject to the limits set forth in the Schedule of Benefits and Limits.
- Birth defects and congenital illnesses. Birth defects are deemed to include hereditary conditions.
- Mental health disorders.
- Pregnancy except as covered under Complications of Pregnancy, as herein defined, termination of pregnancy except in connection with covered Complications of Pregnancy, all charges related to pregnancy after the 26th week of pregnancy, routine prenatal care, child birth, postnatal care, and charges incurred by a child under the age of 14 days.
- Impotency or sexual dysfunction.
- Venereal disease, including all sexually transmitted diseases and conditions.
- HIV, AIDS, or ARC, and all diseases caused by and/or related to HIV.
- All forms of cancer / neoplasm.
- Substance abuse or addiction or conditions that may be attributed to substance abuse or addictions and direct consequences thereof.
- Acne, moles, skin tags, diseases of sebaceous glands, seborrhea, sebaceous cyst, hypertrophic and atrophic conditions of skin, nevus.
- Sleep apnea or other sleep disorders.
- Obesity or weight modification, including but not limited to wiring of the teeth and all forms of intestinal bypass surgery.
- Self-inflicted injury or illness and/or suicide or attempted suicide whether sane or insane.
- Injury sustained that is due wholly or partially to the effects of intoxication or drugs other than drugs taken in accordance with treatment prescribed by a physician and except drugs prescribed for the treatment of substance abuse.
- Injury sustained while operating any motorized vehicle, aircraft or watercraft whether registered or not while under the influence of alcohol as defined under the law of the jurisdiction where the injury occurs or with a .08 BAC whichever is lower.
- Routine medical examinations, including but not limited to vaccinations, immunizations, annual check-ups, the issue of medical certificates and attestations, and examinations as to the suitability of employment or travel.
- Dental treatment and treatment of the temporomandibular joint, except for emergency dental treatment necessary to replace sound natural teeth lost or damaged in an accident covered hereunder or for the emergency relief of acute onset of pain.
- Promotion or prevention of conception including but not limited to: artificial insemination, treatment for infertility, sterilization or reversal of sterilization.
- Organ or tissue transplants or related services.
- Eye surgery, such as corrective refractory surgery, when the primary purpose is to correct nearsightedness, farsightedness or astigmatism.
- Corrective devices and medical appliances, including eyeglasses, contact lenses, hearing aids, hearing implants, eye refraction, visual therapy, and any examination or fitting related to these devices, dentures or dental appliances, and all vision and hearing tests and examinations.
- Orthoptics and visual eye training.
- Orthopedic shoes, orthopedic prescription devices to be attached to or placed in shoes, treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and treatment of corns, calluses or toenails.
- Hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed.
- Speech, vocational, occupational, biofeedback, acupuncture, recreational, sleep or music therapy, holistic care of any nature, massage and kinestherapy.
- Psychometric, intelligence, competency, behavioral and educational testing.
- Cosmetic or aesthetic reasons, except for reconstructive surgery when such surgery is directly related to and follows a surgery which was covered hereunder.
- Modifications of the physical body intended to improve the psychological, mental or emotional well-being, including but not limited to sex-change surgery.
- Exercise programs, whether or not prescribed or recommended by a physician.
- Incurred as a result of exposure to non-medical nuclear radiation and/or radioactive material(s).
- Cryo preservation and implantation or re-implantation of living cells.
- Genetic or predictive testing.
- Investigational, experimental or for research purposes.
- While confined primarily to receive custodial care, educational or rehabilitative care, or any medical treatment in any establishment for the care of the aged, except rehabilitative care received upon direct transfer from an acute care hospital.
- Not medically necessary.
- Not administered by or under the supervision of a physician, and products that can be purchased without a doctor's prescription.
- Provided by a relative, family member or any person who ordinarily resides with you.
- Provided at no cost to you.
- Telephone consultations or failure to keep a scheduled appointment.
- Payable under any government system, including the Australian Medicare system.
- Charges exceeding usual, reasonable and customary.
- Charges resulting from or occurring during the commission of a violation of law, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations.
- Charges resulting from a disease outbreak in a country or location for which the U.S. Centers for Disease Control and Prevention (CDC) has issued a Level 3 Travel Warning if a) the warning has been in effect within the 6 months immediately prior to your date of arrival, or b) within 10 days following the date the warning is issued you have failed to depart the country or location.
- War, military action or while on duty as a member of a police or military force unit.
- Travel or accommodations, except as provided for in the Local Ambulance, Emergency Medical Evacuation, Repatriation of Remains, Emergency Reunion, Natural Disaster, Return of Minor Children, Political Evacuation, and Trip Interruption sections of this insurance.
- Incurred outside your certificate period.
- Submitted to us for payment more than 60 days after the last day of the certificate period.
- When departure from the home country is to obtain treatment in the destination country/countries.
- Complications or consequences of a treatment or condition not covered hereunder.
- Not included as Eligible Expenses as described herein.
Acute Pre-Ex Coverage
This policy does not cover pre-existing conditions, except charges resulting directly from an Acute Onset of Pre-existing Condition subject to the limits set forth in the Schedule of Benefits and Limits.
Pre-existing Condition means any
- Condition for which medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) was recommended or received during the 2 years immediately preceding the certificate effective date; or
- Condition that had manifested itself in such a manner that would have caused a reasonably prudent person to seek medical advice, diagnosis, care, or treatment (includes receiving services and supplies, consultations, diagnostic tests or prescription medicines) within the 2 years immediately preceding the certificate effective date; or
- Injury, illness, sickness, disease, or other physical, medical, mental, or nervous conditions, disorder or ailment (whether known or unknown) that, with reasonable medical certainty, existed at the time of application or within the 2 years immediately preceding the certificate effective date. For the purposes of the Complications of Pregnancy coverage offered hereunder, pregnancy will not be included within the definition of a pre-existing condition.
ACUTE ONSET OF PRE-EXISTING CONDITION
YOU ARE COVERED
- Charges for a sudden and unexpected outbreak or recurrence of a pre-existing condition(s) which:
- Occurs spontaneously and without advance warning either in the form of physician recommendations or symptoms; and
- Is of short duration; and
- Is rapidly progressive; and
- Requires urgent care.
YOU ARE NOT COVERED
unless you fulfill the following condition:
- Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence.
YOU ARE NOT COVERED IF:
- The Acute Onset of a Pre-existing Condition(s) occurs before the certificate effective date; or
- The pre-existing condition is a chronic or congenital condition or that gradually becomes worse over time; or
- The charges are for known, scheduled, required, or expected medical care, drugs or treatments existent or necessary prior to the certificate effective date; or
- Expenses arise directly or indirectly from anything in the General Exclusions.
Premiums will be refunded in full if cancellation request is received prior to the certificate effective date.
Premiums may be refunded after the certificate effective date subject to the following provisions:
- A $25 cancellation fee will apply for administrative costs incurred by us; and
- Only the unused portion of the plan cost will be refunded; and
- You cannot have filed any claims to be eligible for premium refund.
This insurance policy has in it a Claims Procedure which tells you what steps you must take to file a claim, and explains our obligations to you. You shall have 60 days beginning on the last day of the certificate period to submit proof of claim to us.